Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines
Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines
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DOI：
10.1159/000509416
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发表时间：
2020-09-01
影响因子：
2.9
通讯作者：
Goertler, Michael
中科院分区：
文献类型：
--
作者：
Gronemann, Christian;Hause, Stephan;Goertler, Michael
前言：大约每4例中风患者中就有1例继发于心房颤动(房颤)的缺血性中风。虽然有迹象表明，拒绝抗凝以进行二级预防是一种普遍的现象。目的：我们研究了急性卒中中心房颤患者二级预防性抗凝建议和处方的纵向变化，重点关注直接口服抗凝剂(DOAC)的引入和国家卒中预防指南的改变的影响。方法：连续入院的急性脑血管缺血事件患者接受定期诊断检查。假名的临床数据被输入到该机构的中风登记中。结果：2009年1月至2018年12月收治的7175例房颤患者中，有1812例(25.3%)发生了房颤引起的卒中。在观察期内，患者接受推荐抗凝治疗的频率从66.7%增加到95.8%(每年；调整后的优势比[OR]，1.309；可信区间[CI]，1.153-1.486)。独立于这一时间趋势，DOAC批准(调整后的OR，4.026；CI 1.962-8.265)和指南的改变(调整后的OR，2.184；CI，1.006-4.743)与推荐抗凝治疗的频率增加相关。出院时已经接受二级预防的推荐抗凝治疗的患者比例从42.1%增加到62.5%。DOAC的引入与这一趋势无关，指南的改变甚至与出院时抗凝患者频率的减少有关(调整后的OR，0.641；CI，0.414-0.991)。对早期脑出血的恐惧是出院时拒绝抗凝的最常见原因(37%)，并在观察期间保持稳定。结论：随着国家指南的改变，抗凝禁忌症的取消和DOAC的引入，口服抗凝得到了更广泛的推荐。然而，新的指南和DOAC都没有发现与我们医院已经出院的患者中推荐的抗凝剂预防的比例增加有关。这可能是由于研究期间住院时间的减少以及缺乏急性脑梗塞患者DOAC早期出血风险的证据所致。需要循证数据来弥合这一治疗差距。
Introduction:Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon.Objective:We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines.Methods:Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution's stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital.Results:Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153-1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962-8.265) and guideline change (adjusted OR, 2.184; CI, 1.006-4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414-0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital discharge and stayed stable during the observation period.Conclusions:Changing national guidelines with discard of contraindications for anticoagulation and the introduction of DOACs led to a broader recommendation of oral anticoagulation. However, both, new guidelines and DOACs, were not found to be associated with an increasing percentage of patients discharged from our hospital already on recommended anticoagulant prevention. This might be explained by the decreasing length of hospital stay during the study period and a missing evidence of early bleeding risk of DOACs in patients with acute brain infarction. Evidence-based data to close this therapeutic gap are needed.