Suboptimal AF management of concern in stroke prevention

Management of stroke risk factors is improving, but remains suboptimal, especially in patients with atrial fibrillation (AF), say UK researchers.

"Patients with AF, who do particularly poorly after stroke, do not appear to be appropriately risk stratified for anticoagulation therapy," say Martin Cowie (Imperial College London) and co-workers in the BMJ Open.

"Improved detection of AF and thromboprophylaxis in such patients should be a priority for healthcare systems."
The team identified 32,151 patients in the UK General Practice Research Database who had a first-ever stroke between 1999 and 2008. Of these patients, 65.2% had physician-diagnosed hypertension, 38.7% had hypercholesterolemia, 44.2% were smokers, 11.8% had diabetes, and 10.8% had AF.

Use of secondary medications rose over the study period, report Cowie et al. For example, use of antihypertensive agents in the year before stroke increased from about 50% to about 65%, while use of lipid-lowering drugs rose from less than 5% to more than 30%.

Risk-factor management improved in the year after patients' strokes, with 70% to 80% of patients receiving antihypertensives, lipid-lowering drugs, and antiplatelet agents in 2008.

But use of anticoagulants rose only slightly during the study period, to a little under 10% in the year before stroke and over 10% in the year after.

A quarter of patients with AF were taking anticoagulants in the year before their strokes, but use of anticoagulants did not rise in line with increasing CHADS[SUB]2[/SUB] score (indicating increasing stroke risk).

By contrast, "we found that antiplatelet prescribing increased significantly with increasing CHADS[SUB]2[/SUB] score, indicating that [general practitioners] might be responding to increasing thromboembolic risk by prescribing an antiplatelet agent rather than an anticoagulant," say the researchers.

Nevertheless, stroke incidence fell by 30% over the study period, from 1.48 per 1000 person-years in 1999 to 1.04 per 1000 person-years in 2008, although overall prevalence increased slightly. Mortality after stroke fell, from 21% in 1999 to 12% in 2008.

"This is likely to be due (at least partially) to much better identification of vascular risk and the prescription of preventive therapies prior to, and after, stroke," concludes the team.

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