Article Text

Download PDFPDF

Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA
  1. Duncan Wilson1,2,
  2. Gareth Ambler3,
  3. Clare Shakeshaft2,
  4. Gargi Banerjee2,
  5. Andreas Charidimou4,5,
  6. David Seiffge2,
  7. Mark White2,
  8. Hannah Cohen6,
  9. Tarek Yousry7,
  10. Rustam Salman8,
  11. Gregory Y H Lip9,
  12. Keith Muir10,
  13. Martin M Brown11,
  14. H R Jäger4,
  15. David J Werring12
  16. on behalf of the CROMIS-2 collaborators
    1. 1 New Zealand Brain Research Institute, Christchuch, New Zealand
    2. 2 Brain Repair and Rehabilitation, Institute of Neurology, UCL, London, UK
    3. 3 Department of Statistical science, University College London, London, UK
    4. 4 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
    5. 5 Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts, USA
    6. 6 Haemostasis Research Unit, Department of Haematology, University College London, London, UK
    7. 7 Lysholm Department of Neuroradiology, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
    8. 8 Centre for clinical brain sciences, University of Edinburgh, Edinburgh, UK
    9. 9 Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
    10. 10 University of Glasgow, Glasgow, UK
    11. 11 Neurology, UCL, London, UK
    12. 12 Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
    1. Correspondence to Dr Duncan Wilson; duncan.wilson{at}ucl.ac.uk

    Abstract

    Objective We report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients with newly diagnosed AF, in a cohort of patients who presented with ischaemic stroke or transient ischaemic attack (TIA) not previously treated with anticoagulation.

    Design We reviewed cross-sectional baseline demographic and clinical data from a prospective observational cohort study, (CROMIS-2).

    Setting Patients were recruited from 79 hospital stroke centres throughout the UK and one centre in the Netherlands.

    Participants Patients were eligible if they were adults who presented with ischaemic stroke or TIA and AF and had not been previously treated with oral anticoagulation.

    Main outcome measures Proportion of patients with known AF before index ischaemic stroke or TIA from a cohort of patients who have not been previously treated with oral anticoagulation. Secondary analysis includes the comparison of CHA2DS2-VASc and HAS-BLED scores and other demographics and risk factors between those with newly diagnosed AF and those with previously known AF.

    Results Of 1470 patients included in the analysis (mean age 76 years (SD 10)), 622 (42%) were female; 999 (68%) patients had newly diagnosed AF and 471 (32%) patients had known AF. Of the 471 patients with known AF, 68% had a strong indication for anticoagulation and 89% should have been considered for anticoagulation based upon CHA2DS2-VASc score. Patients with known AF were more likely to have a prior history of dementia (4% vs 2%, p=0.02) and had higher HAS-BLED scores (median 3 vs 2). CHA2DS2-VASc, other risk factors and demographics were similar.

    Conclusions About 1/3 of patients who present with stroke and have AF who have not been treated with oral anticoagulation have previously known AF. Of these patients, at least 68% were not adequately treated with oral anticoagulation.

    Trial registration number NCT02513316.

    • atrial fibrillation
    • stroke
    • anticoagulation

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

    View Full Text

    Statistics from Altmetric.com

    Footnotes

    • Contributors DW drafted and revised the manuscript, was involved in study concept and analysis, interpretation of data and statistical analysis. GA revised the manuscript analysis and interpretation of data and statistical analysis. GB contributed to data acquisition and manuscript revision. CS revised the manuscript, coordinated the study and acquisition of data. AC revised the manuscript and was involved with acquisition of data. DS revised the manuscript. MW revised the manuscript and was involved with acquisition of data. HC revised the manuscript and was involved with study design. TY revised the manuscript and was involved with study design. RS revised the manuscript and was involved with study design. GYHL revised the manuscript and was involved with study design. KM revised the manuscript and was involved with study design. MMB revised the manuscript and was involved with study design. HRJ revised the manuscript was involved with study design and analysis of data. DJW revised the manuscript, was involved in study concept and design, analysis and interpretation of data, study supervision and obtaining funding.

    • Funding CROMIS-2 is funded by the Stroke Association and British Heart Foundation and this study was funded by University College London.

    • Competing interests None declared.

    • Ethics approval Ethics for CROMIS-2 approved by National Research Ethics Service, Central London (IRAS reference 10/H0716/61).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data will be made available upon reasonable request to the steering committee.

    • Collaborators Kirsty Harkness, MD, Louise Shaw, MD, Jane Sword, MD, Azlisham Mohd Nor, MD, Pankaj Sharma, PhD, Roland Veltkamp, MD, Deborah Kelly, MD, Frances Harrington, MD, Marc Randall, MD, Matthew Smith, MD, Karim Mahawish, MD, Abduelbaset Elmarim, MD, Bernard Esisi, MD, Claire Cullen, MD, Arumug Nallasivam, MD, Christopher Price, MD, Adrian Barry, MD, Christine Roffe, MD, John Coyle, MD, Ahamad Hassan, MD, Caroline Lovelock, DPhil, Jonathan Birns, MD, David Cohen, MD, L Sekaran, MD, Adrian Parry-Jones, PhD, Anthea Parry, MD, David Hargroves, MD, Harald Proschel, MD, Prabel Datta, MD, Khaled Darawil, MD, Aravindakshan Manoj, MD, Mathew Burn, MD, Chris Patterson, MD, Elio Giallombardo, MD, Nigel Smyth, MD, Syed Mansoor, MD, Ijaz Anwar, MD, Rachel Marsh, MD, Sissi Ispoglou, MD, Dinesh Chadha, MD, Mathuri Prabhakaran, MD, Sanjeevikumar Meenakishundaram, MD, Janice O’Connell, MD, Jon Scott, MD, Vinodh Krishnamurthy, MD, Prasanna Aghoram, MD, Michael McCormick, MD, Nikola Sprigg MD, Paul O’Mahony, MD, Martin Cooper, MD, Lillian Choy, MD, Peter Wilkinson, MD, Simon Leach, MD, Sarah Caine, MD, Ilse Burger, MD, Gunaratam Gunathilagan, MD, Paul Guyler, MD, Hedley Emsley, MD, Michelle Davis, MD, Dulka Manawadu, MD, Kath Pasco, MD, Maam Mamun, MD, Robert Luder, MD, Mahmud Sajid, MD, Ijaz Anwar, MD, James Okwera, MD, Julie Staals, PhD, Elizabeth Warburton, MD, Kari Saastamoinen, MD, Timothy England, MD, Janet Putterill, MD, Enrico Flossman, MD, Michael Power, MD, Krishna Dani, MD, David Mangion, MD, Appu Suman, MD, John Corrigan, MD, Enas Lawrence, MD, and Djamil Vahidassr, MD.

    • Patient consent for publication Written informed consent was obtained from all participants (or consultees of participants).

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.