Rates and Determinants of 5-Year Outcomes After Atrial Fibrillation–Related Stroke

Derek T. Hayden, Niamh Hannon, Elizabeth Callaly, Danielle Ní Chróinín, Gillian Horgan, Lorraine Kyne, Joseph Duggan, Eamon Dolan, Killian O'Rourke, David Williams, Sean Murphy, Peter J. Kelly
2015 Stroke  
A trial fibrillation (AF) confers a 5-fold increase in stroke risk and is reported in 13% to 31% of incident ischemic stroke in population studies. 1,2 The prevalence of AF rises steeply with increasing age and is projected to increase 2.5fold within the next 40 years as a result of population growth and aging. 3 These demographic trends in AF incidence and prevalence may yield a substantial rise in the societal burden of AF-related stroke (AF-stroke) in the coming decades. 4, 5 It is well
more » ... lished that AF-stroke is associated with greater early severity, disability, fatality, and cost compared with non-AF stroke. 6-9 However, little population-based data exist on late outcomes and utilization of secondary prevention medication in survivors after AF-stroke. Such data are important when counseling individual patients and families in clinical practice. Accurate data are also essential to inform populationwide health service planning to improve AF detection, stroke Background and Purpose-Demographic trends in atrial fibrillation (AF) incidence may yield a substantial rise in the societal burden of AF-related stroke (AF-stroke). Accurate population-wide outcome data are essential to inform health service planning to improve AF-stroke prevention, and provision of rehabilitation, nursing home, and community supports for AF-stroke survivors. Methods-We investigated rates and determinants of 5-year fatality, stroke recurrence, functional outcomes, and prescribing of secondary prevention medications in AF-stroke in the North Dublin Population Stroke Study. Ascertainment included hot and cold pursuit using multiple overlapping sources. Survival analysis was performed using lifetables and Kaplan-Meier survival curves, and Cox proportional hazard modeling was performed to identify predictors of death and recurrent stroke. Results-Five hundred sixty-eight patients with new stroke were identified, including 177 (31.2%) AF-stroke. At 5 years, 39.2% (confidence interval, 31.5-46.8) of ischemic AF-stroke patients were alive. Congestive heart failure, hypertension, age <65, 65-74 years, and ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack or thromboembolism, vascular disease and female sex (CHA 2 DS 2 -VASc) score (hazard ratio [HR], 1.34; P<0.001), CHADS 2 score (HR 1.42, P=0.004), National Institute of Health Stroke Scale (HR, 1.09; P<0.0001), and subtherapeutic international normalized ratio (<2.0) at stroke onset (HR, 3.29; P=0.003) were independently associated with 5-year fatality, whereas warfarin (HR, 0.40; P=0.001) and statin use after index stroke (HR, 0.52; P=0.005) were associated with improved survival. The 5-year recurrence rate after ischemic AF-stroke was 21.5% (confidence interval, 14.5-31.3). Trends toward greater risk of recurrence were observed for persistent AF (HR, 3.09; P=0.07) and CHA 2 DS 2 -VASc score (HR, 1.34; P=0.07). Nursing home care was needed for 25.9% of patients. Conclusions-AF-stroke is associated with considerable long-term morbidity, fatality, stroke recurrence, and nursing home requirement. Adequately resourced national AF strategies to improve AF detection and prevention are needed. (D.W., S.M.). The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/
doi:10.1161/strokeaha.115.011139 pmid:26470776 fatcat:4gkcaordbjegjorygd4pw7q3ry