Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea.
Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea.
Europace. 2024 Feb 1;26(2). doi: 10.1093/europace/euae033.
Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS.
Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy.
Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.
关于房颤（AF）和急性缺血性卒中（IS）患者抗栓药物的最佳使用以及相关临床结局的数据有限。我们研究了 AF 合并急性 IS 患者在卒中后早期抗栓治疗情况下，社区实践中抗栓药物的使用模式和长期临床预后。
回顾性分析了 2010 年至 2020 年在一家三级医院因急性 IS 住院的 AF 患者。确定了临床特征，包括卒中病因和抗栓药物的使用模式。根据出院后第一次门诊随访时的抗栓治疗[单独口服抗凝剂（OAC）、单独抗血小板治疗（APT）或 OAC/APT(s)]，比较了净临床结局（NCO）-卒中复发、任何出血、因心血管（CV）事件住院或急诊就诊以及死亡的复合结局。共分析了 918 例 AF 合并急性 IS 患者（平均年龄 72.6 岁；男性 59.3%；平均 CHA₂DS₂-VASc 评分为 3.3）。三分之一（33.9%，n=310）的患者同时诊断为 AF 和 IS。IS 的最常见病因是心源性栓塞（71.2%），其次是病因不明（19.8%）和大动脉粥样硬化（6.0%）。在住院期间，33.4%、11.1%和 53.4%的患者使用了 OAC、APT(s)和 OAC 和 APT(s)联合治疗，而在第一次门诊时，分别有 67.0%、9.1%和 21.7%的患者使用了上述药物，并且在 IS 后 1 年以上，这些药物大多持续使用。有 11.3%的卒中后 AF 患者未使用 OAC。在中位随访 2.1 年期间，每 100 患者年（PY）的 NCO 总发生率为 20.14。APT(s)单药治疗的 NCO 累积风险最高（校正后风险比 1.47，95%置信区间 1.08-2.00，P=0.015；与 OAC 单药治疗相比），主要是因为卒中复发和任何出血的发生率最高。OAC/APT(s)联合治疗与更高的卒中复发风险（P=0.040）和略高的任何出血风险相关（与 OAC 单药治疗相比）。
大约三分之一的 AF 合并急性 IS 的发病机制与心源性栓塞不同。尽管在 AF 合并急性 IS 患者中经常使用 APT，但未观察到额外的临床获益。AF 合并 IS 患者应坚持 OAC 治疗，以预防进一步的 CV 不良事件。
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