Does prior antithrombotic therapy influence stroke recurrence and bleeding risk in patients with atrial fibrillation and flutter?

David T. Gamble (Corresponding Author), Romain Buono, Mamas A. Mamas, Stephen Leslie, Joao H. Bettencourt-Silva, Allan B. Clark, Kristian M. Bowles, Anthony Kneale Metcalf, John F. Potter, Phyo K Myint

Research output: Contribution to journalArticle

Abstract

Background
Whilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.

Methods
We used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA2DS2-VASc) and bleeding risk score (HEMORR2HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.

Results
A total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHA2DS2-VASc (≥2) and high HEMORR2HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48–1.00: p = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71–0.97: p = 0.02)).

Conclusions
Our study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.
Original languageEnglish
JournalEuropean Journal of Preventive Cardiology
Early online date3 Sep 2019
DOIs
Publication statusE-pub ahead of print - 3 Sep 2019

Fingerprint

Atrial Flutter
Atrial Fibrillation
Stroke
Hemorrhage
Recurrence
Therapeutics
Confidence Intervals
Mortality
Risk Reduction Behavior
Hospital Mortality
Proportional Hazards Models
Logistic Models
Odds Ratio
Phenotype
Survival

Keywords

  • stroke
  • atrial fibrillation
  • thromboprophylaxis
  • antithrombotic treatment
  • MORTALITY
  • Stroke
  • MANAGEMENT
  • HEMORRHAGE
  • SCORES
  • PREVENTION
  • OUTCOMES
  • PREDICTION

Cite this

Does prior antithrombotic therapy influence stroke recurrence and bleeding risk in patients with atrial fibrillation and flutter? / Gamble, David T. (Corresponding Author); Buono, Romain; Mamas, Mamas A.; Leslie, Stephen; Bettencourt-Silva, Joao H.; Clark, Allan B.; Bowles, Kristian M.; Metcalf, Anthony Kneale; Potter, John F.; Myint, Phyo K.

In: European Journal of Preventive Cardiology, 03.09.2019.

Research output: Contribution to journalArticle

Gamble, David T. ; Buono, Romain ; Mamas, Mamas A. ; Leslie, Stephen ; Bettencourt-Silva, Joao H. ; Clark, Allan B. ; Bowles, Kristian M. ; Metcalf, Anthony Kneale ; Potter, John F. ; Myint, Phyo K. / Does prior antithrombotic therapy influence stroke recurrence and bleeding risk in patients with atrial fibrillation and flutter?. In: European Journal of Preventive Cardiology. 2019.
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title = "Does prior antithrombotic therapy influence stroke recurrence and bleeding risk in patients with atrial fibrillation and flutter?",
abstract = "BackgroundWhilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.MethodsWe used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA2DS2-VASc) and bleeding risk score (HEMORR2HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.ResultsA total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8{\%} women) with prior atrial fibrillation were included. Of these, 1761 (91.3{\%}) suffered ischaemic stroke. The most common phenotype (64{\%}) was of those with both high CHA2DS2-VASc (≥2) and high HEMORR2HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31{\%} for in-hospital mortality (odds ratio 0.69 (95{\%} confidence interval 0.48–1.00: p = 0.049)) and 17{\%} relative risk reduction for long-term mortality (hazard ratio 0.83 (95{\%} confidence interval 0.71–0.97: p = 0.02)).ConclusionsOur study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.",
keywords = "stroke, atrial fibrillation, thromboprophylaxis, antithrombotic treatment, MORTALITY, Stroke, MANAGEMENT, HEMORRHAGE, SCORES, PREVENTION, OUTCOMES, PREDICTION",
author = "Gamble, {David T.} and Romain Buono and Mamas, {Mamas A.} and Stephen Leslie and Bettencourt-Silva, {Joao H.} and Clark, {Allan B.} and Bowles, {Kristian M.} and Metcalf, {Anthony Kneale} and Potter, {John F.} and Myint, {Phyo K}",
note = "The authors would like to thank the patients of the NNUH Stroke Register cohort and the data team of the Norfolk and Norwich University Stroke Services. NNUH Stroke Register is maintained by the NNUH Stroke Services.",
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T1 - Does prior antithrombotic therapy influence stroke recurrence and bleeding risk in patients with atrial fibrillation and flutter?

AU - Gamble, David T.

AU - Buono, Romain

AU - Mamas, Mamas A.

AU - Leslie, Stephen

AU - Bettencourt-Silva, Joao H.

AU - Clark, Allan B.

AU - Bowles, Kristian M.

AU - Metcalf, Anthony Kneale

AU - Potter, John F.

AU - Myint, Phyo K

N1 - The authors would like to thank the patients of the NNUH Stroke Register cohort and the data team of the Norfolk and Norwich University Stroke Services. NNUH Stroke Register is maintained by the NNUH Stroke Services.

PY - 2019/9/3

Y1 - 2019/9/3

N2 - BackgroundWhilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.MethodsWe used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA2DS2-VASc) and bleeding risk score (HEMORR2HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.ResultsA total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHA2DS2-VASc (≥2) and high HEMORR2HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48–1.00: p = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71–0.97: p = 0.02)).ConclusionsOur study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.

AB - BackgroundWhilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.MethodsWe used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA2DS2-VASc) and bleeding risk score (HEMORR2HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.ResultsA total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHA2DS2-VASc (≥2) and high HEMORR2HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48–1.00: p = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71–0.97: p = 0.02)).ConclusionsOur study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.

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KW - atrial fibrillation

KW - thromboprophylaxis

KW - antithrombotic treatment

KW - MORTALITY

KW - Stroke

KW - MANAGEMENT

KW - HEMORRHAGE

KW - SCORES

KW - PREVENTION

KW - OUTCOMES

KW - PREDICTION

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DO - 10.1177/2047487319871709

M3 - Article

JO - European Journal of Preventive Cardiology

JF - European Journal of Preventive Cardiology

SN - 2047-4873

ER -