Use of Oral Anticoagulant Therapy in Older Adults With Atrial Fibrillation After Acute Ischemic Stroke

Emer R. McGrath, MB, PhD; Alan S. Go, MD; Yuchiao Chang, PhD; Leila H. Borowsky, MPH; Margaret C. Fang, MD, MPH; Kristi Reynolds, PhD, MPH; Daniel E. Singer, MD

Disclosures

J Am Geriatr Soc. 2017;65(2):241-248. 

In This Article

Abstract and Introduction

Abstract

Objectives: To explore barriers to anticoagulation in older adults with atrial fibrillation (AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants (OACs).

Design: Retrospective cohort study.

Setting: Two large community-based AF cohorts.

Participants: Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79).

Measurements: Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse.

Results: Median CHA2DS2-VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio (OR) = 8.96, 95% confidence interval (CI) = 5.01–16.04 for aged ≥85 vs <65) and disability (OR = 12.58, 95% CI = 5.82–27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC (P < .001), far higher than recurrent stroke rates.

Conclusion: Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals.

Introduction

Prior ischemic stroke is one of the most important risk factors for recurrent ischemic stroke in individuals with atrial fibrillation (AF).[1] Oral anticoagulant (OAC) therapy can reduce the risk of ischemic stroke by two-thirds in individuals with AF with prior ischemic stroke.[2] Despite this, a large proportion of individuals with AF are not prescribed an OAC after ischemic stroke.[3] There is a lack of understanding of the reasons why OAC therapy is not prescribed for such individuals at very high risk of recurrent ischemic stroke. Previous studies primarily included individuals at lower stroke risk without prior stroke[4] and were limited by small sample sizes.[4–6] Greater insights into nonuse of OAC therapy in high-risk secondary prevention populations may enable targeted interventions to increase appropriate use of OAC therapy in suitable candidates, including individuals with AF without prior stroke who are otherwise at high stroke risk. The current study explored the reasons for not prescribing OAC therapy after acute ischemic stroke in two large community-based cohorts of individuals with AF.

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