Secular Trends in Outcomes and Impact of Novel Oral Anticoagulants in Atrial Fibrillation-Related Acute Ischemic Stroke

Minwoo Lee, Byung Chul Lee, Kyung Ho Yu, Mi Sun Oh, Beom Joon Kim, Jun Yup Kim, Jihoon Kang, Keon Joo Lee, Do Yeon Kim, Jong Moo Park, Kyusik Kang, Tai Hwan Park, Kyung Bok Lee, Keun Sik Hong, Hong Kyun Park, Yong Jin Cho, Dong Eog Kim, Soo Joo Lee, Jae Guk Kim, Jun LeeJae Kwan Cha, Dae Hyun Kim, Joon Tae Kim, Kang Ho Choi, Jay Chol Choi, Sung Il Sohn, Jeong Ho Hong, Sang Hwa Lee, Chulho Kim, Dong Ick Shin, Kyu Sun Yum, Juneyoung Lee, Ji Sung Lee, Philip B. Gorelick, Hee Joon Bae*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

BACKGROUND: Novel oral anticoagulants (NOACs) are currently recommended for the secondary prevention of stroke in patients with acute ischemic stroke (AIS) accompanied by atrial fibrillation (AF). However, the impact of NOACs on clinical outcomes in real-world practice remains ambiguous. This study analyzes the trend of clinical events in patients with AF-related AIS and determines how much the introduction of NOACs has mediated this trend. METHODS: We identified patients with AIS and AF between January 2011 and December 2019 using a multicenter stroke registry. Annual rates of NOAC prescriptions and clinical events within 1 year were evaluated. The primary outcome was a composite of recurrent stroke, myocardial infarction, and all-cause mortality. To assess the mediation effect of NOACs on the relationship between the calendar year and these outcomes, we used natural effect models and conducted exposure-mediator, exposure-outcome, and mediator-outcome analyses using multivariable regression models or accelerated failure time models, adjusting for potential confounders. RESULTS: Among the 12 977 patients with AF-related AIS, 12 500 (average age: 74.4 years; 51.3% male) were analyzed after excluding cases of valvular AF. Between 2011 and 2019, there was a significant decrease in the 1-year incidence of the primary composite outcome from 28.3% to 21.7%, while the NOAC prescription rate increased from 0% to 75.6%. A 1-year increase in the calendar year was independently associated with delayed occurrence of the primary outcome (adjusted time ratio, 1.10 [95% CI, 1.07-1.14]) and increased NOAC prescription (adjusted odds ratio, 2.20 [95% CI, 2.14-2.27]). Increased NOAC prescription was associated with delayed occurrence of the primary outcome (adjusted time ratio, 3.82 [95% CI, 3.17 to 4.61]). Upon controlling for NOAC prescription (mediator), the calendar year no longer influenced the primary outcome (adjusted time ratio, 0.97 [95% CI, 0.94-1.00]). This suggests that NOAC prescription mediates the association between the calendar year and the primary outcome. CONCLUSIONS: Our study highlights a temporal reduction in major clinical events or death in Korean patients with AF-related AIS, mediated by increased NOAC prescription, emphasizing NOAC use in this population.

Original languageEnglish (US)
Pages (from-to)625-633
Number of pages9
JournalStroke
Volume55
Issue number3
DOIs
StatePublished - Mar 1 2024

Keywords

  • anticoagulation
  • atrial fibrillation
  • death
  • ischemic stroke
  • major vascular event
  • stroke recurrence

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

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