Lip Gregory Y H, Hunter Tina D, Quiroz Maria E, Ziegler Paul D, Turakhia Mintu P
From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.).
Circ Cardiovasc Qual Outcomes. 2017 Jan;10(1). doi: 10.1161/CIRCOUTCOMES.116.002864.
The risk of recurrence after an initial ischemic stroke or transient ischemic attack (TIA) may be impacted by undiagnosed atrial fibrillation (AF). We therefore assessed the impact of AF diagnosis and timing on stroke/TIA recurrence rates in a large real-world sample of patients.
Using commercial claims data (Truven Health Analytics MarketScan), we performed a retrospective cohort study of patients with an index stroke or TIA event recorded in years 2008 through 2011. Patients were characterized by baseline oral anticoagulation, CHADS and CHADS-VASc scores, AF diagnosis and timing with respect to the index stroke, and presence or absence of post-index ambulatory cardiac monitoring. The primary outcome was the recurrence of an ischemic stroke or TIA. Of 179 160 patients (age 67±16.2 years; 53.7% female), the Kaplan-Meier estimate for stroke/TIA recurrence within 1 year was 10.6%. Not having oral anticoagulation prescribed at baseline and having AF first diagnosed >7 days post-stroke (late AF) was highly associated with recurrent stroke/TIA (hazard ratio, 2.0; 95% confidence interval, 1.9-2.1). Among patients with at least 1 year of follow-up, only 2.6% and 9.7% had ambulatory ECG monitoring in the 7 days and 12 months post-stroke, respectively.
AF diagnosed after stroke is an important hallmark of recurrent stroke risk. Increasing the low utilization of cardiac monitoring after stroke could identify undiagnosed AF earlier, leading to appropriate oral anticoagulation treatment and a reduction in stroke/TIA recurrence.
初次缺血性卒中或短暂性脑缺血发作（TIA）后复发风险可能受到未诊断出的心房颤动（AF）的影响。因此，我们在一个大型真实世界患者样本中评估了AF诊断及诊断时机对卒中/TIA复发率的影响。
利用商业索赔数据（Truven Health Analytics MarketScan），我们对2008年至2011年记录有首次卒中或TIA事件的患者进行了一项回顾性队列研究。患者的特征包括基线口服抗凝治疗情况、CHADS和CHADS-VASc评分、相对于首次卒中的AF诊断及诊断时机，以及首次卒中后是否进行门诊心脏监测。主要结局是缺血性卒中或TIA的复发。在179160例患者（年龄67±16.2岁；53.7%为女性）中，1年内卒中/TIA复发的Kaplan-Meier估计值为10.6%。基线时未开具口服抗凝治疗且卒中后>7天首次诊断出AF（迟发性AF）与复发性卒中/TIA高度相关（风险比，2.0；95%置信区间，1.9 - 2.1）。在至少随访1年的患者中，分别只有2.6%和9.7%在卒中后7天和12个月进行了动态心电图监测。
卒中后诊断出的AF是复发性卒中风险的一个重要标志。提高卒中后心脏监测的低利用率可更早识别未诊断出的AF，从而导致适当的口服抗凝治疗并降低卒中/TIA复发率。
