ESC Congress in Review - Main Edition 2019 - 26

Late-Breaking Science

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Increased Oral Anticoagulation
Use Associated with Less
Ischaemic Stroke in AF Patients
Written by Lisa Buttle

A rise in use of oral anticoagulation among patients
with atrial fibrillation (AF), largely driven by growing prescription of non-vitamin K oral anticoagulants
(NOACs), is associated with a decline in hospital admissions for ischaemic stroke. This was a key finding of a
4-year database study involving over 13 million Italian
inhabitants presented by Aldo Pietro Maggioni, MD,
Research Centre of the Italian Association of Hospital
Cardiologists, Florence, Italy.
The aim of this 4-year analysis (2012 to 2015) of
the Ricerca e Salute (ReS) database was to assess
rates of hospitalisations for AF, ischaemic stroke, and
major haemorrhage, prescription of oral anticoagulants
and antiplatelet agents, and to evaluate annual costs
per patient with AF. Patients discharged alive after an
admission for AF (primary or secondary; n = 194,030)
were followed for 1 year to measure medication use and
further hospitalisations.
The study found that ~4 in every 1,000 people in
Italy are admitted each year with AF, a number that
remained stable from 2012 to 2015. The proportion

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October 2019

Figure 11. Yearly Trends in Antithrombotic Drug Use and in
Admissions for Ischaemic or Haemorrhagic Stroke and Major Bleeds
25

140
120

20

100

15

80
60

10

40

5
0

20

2012

2013

2014

2015

Yearly DDD per AF Patients

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of patients treated with a vitamin K antagonist (VKA)
dropped	during	this	time	(from	55.9%	to	36.7%)	while	
the proportion taking a NOAC increased from < 1% in
2012	to	27.7%	in	2015.	Overall	the	use	of	any	oral	anticoagulant	increased	from	56.7%	to	64.4%.	At	the	same	
time,	antiplatelet	therapy	use	-which	is	not	recommended in the guidelines for stroke prevention in AF patients
-	fell	from	42.6%	to	28.1%.	
The 1-year rate of hospitalisation for ischaemic
stroke declined by around one-third from 21.3% in 2012
to	 14.7%	 in	 2015.	 The	 rate	 of	 haemorrhagic	 stroke	 fell	
from 6.5% to 4.1% during the study period, and major
bleeding increased from 1.5% to 2.3% (Figure 11).

Hospital Aadmissions
per 1,000 Patients with AF

	 Patients	who	had	received	PCI	accounted	for	58%	of	
the total THEMIS population. Among these patients in
THEMIS-PCI, the prespecified subgroup analysis, 404 of
5,558	 (7.3%)	 participants	 taking	 ticagrelor	 plus	 aspirin	
experienced cardiovascular death, myocardial infarction,
or	 stroke	 versus	 480	 of	 5,596	 (8.6%)	 participants	 taking placebo plus aspirin -the relative reduction was 15%
in	patients	with	prior	PCI	(HR,	0.85;	95%	CI,	0.74	to	0.97;	
P = .013). Major bleeding occurred in 111 of 5,536 (2.0%)
patients receiving ticagrelor and in 62 of 5,564 (1.1%)
patients	receiving	placebo	(HR,	2.03;	95%	CI,	1.48	to	2.76;	
P < .0001]. The risk for intracranial bleeding was similar
between ticagrelor and placebo (33 patients vs 31 patients,
respectively). For patients without prior PCI, there was no
significant between-group difference in the predefined
exploratory outcome of irreversible harm (death from any
cause, myocardial infarction, stroke, fatal bleeding, or intracranial haemorrhage). Prof. Steg concluded: "The results
suggest that long-term therapy with ticagrelor in addition
to aspirin may be considered in patients with diabetes and
a history of PCI who have tolerated antiplatelet therapy
and have high ischaemic risk and low bleeding risk. This is
a novel therapeutic option for a large and easy to identify
patient population."

0

Ischaemic strokes per 1,000 AF patients
Haemorrhagic strokes per 1,000 AF patients
Major bleeding events per 1,000 AF patients
Vitamin K antagonists (yearly DDD/AF patients)
NOACs (yearly DDD/AF patients)
Antiplatelet (yearly DDD/AF patients)

AF, atrial fibrillation; DDD, defined daily dose; NOAC, non-vitamin K oral
anticoagulants.
Reproduced with kind permission from Maggioni AP, Dondi L, Andreotti F et al.

The study also investigated the annual total cost
of treating patients with AF (including drug prescriptions, outpatient services, and hospitalisations), which
declined	 from	 €5,927	 in	 2012	 to	 €5,239	 in	 2015.	 While	
more money was spent on NOACs, the costs associated
with hospitalisations decreased, and the cost of other
medications that became generic in 2015 was lower.
Prof. Maggioni concluded that, while there have
been promising trends in guideline-recommended drug
prescription and a reduced number of hospitalisations
due to ischaemic stroke, this analysis represents only
a descriptive association between these findings and
cannot demonstrate causality. However, the findings
are consistent with a recent 10-year study from England
that showed an association between increased uptake of
oral anticoagulation and a reduction in hospitalisations
for strokes related to AF [Cowan JC et al. Eur Heart J.
2018].
Replay presentation on ESC365

medicom-publishers.com/mcr

https://esc365.escardio.org/Congress/ESC-CONGRESS-2019/Hot-Line-Session-1/202346-themis-pci-ticagrelor-in-patients-with-diabetes-and-stable-coronary-artery-disease-with-a-history-of-prior-percutaneous-coronary-intervention https://esc365.escardio.org/Congress/ESC-CONGRESS-2019/Hot-Line-Session-1/202150-themis-main-results-of-the-effect-of-ticagrelor-on-health-outcomes-in-diabetes-mellitus-patients-intervention-study https://esc365.escardio.org/Congress/ESC-CONGRESS-2019/Late-Breaking-Science-in-Atrial-Fibrillation-1/202086-four-year-trends-in-oral-anticoagulant-use-and-rate-of-ischemic-stroke-among-194-030-atrial-fibrillation-patients-taken-from-a-population-of-13-million-people http://www.medicom-publishers.com/mcr

ESC Congress in Review - Main Edition 2019

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