WSO - March 2024 - 342

1206680
WSO
International Journal of StrokeHarbison et al.
Research
Changes in anticoagulation practice
in subjects admitted with stroke
associated with atrial fibrillation,
following introduction of direct oral
anticoagulants over 2013-2021
Joseph Harbison1,2,3 , Joan McCormack1, Olga Brych1 , Ronan
Collins1,2, Niamh O'Connell4, Mary Randles2, Cormac Kennedy5,
Peter J Kelly6,7 and Tim Cassidy1,8
Abstract
Background: The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in
atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate
changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis.
Methods: AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021
were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known
AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice
were assessed.
Results: AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and
56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The
proportion all total IS due to AF decreased by 15.3% (31.3%−26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH
did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with
AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a
DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse
correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes
over time (r = −0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14,
p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = −0.83, p = 0.006) and also
correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = −0.89, p = 0.001)
Conclusion: DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a
reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated
with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.
Keywords
Anticoagulation, stroke, population study, audit
Received: 19 July 2023; accepted: 15 September 2023
1Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
2Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
3Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
4National Coagulation Centre, St. James's Hospital, Dublin, Ireland
5Department of Pharmacology & Therapeutics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
6Department of Neurology, University College Dublin, Dublin, Ireland
7Institute of Neurology, The Mater Hospital, Dublin, Ireland
8Acute Stroke Service, St. Vincent's University Hospital, Dublin, Ireland
Corresponding author:
Joseph Harbison, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin D08 W9RT, Ireland.
Email: jharbiso@tcd.ie
International Journal of Stroke, 19(3)
International Journal of Stroke
2024, Vol. 19(3) 342 -347
© 2023 World Stroke Organization
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