P514Do atrial fibrillation patients with history of cerebrovascular accidents receive guideline-concordant stroke preventive therapies? Insights from the prospective SPRINT-AF registry

Abstract

Background/Introduction: Canadian and international guidelines recommend that atrial fibrillation (AF) patients with a history of stroke or transient ischemic attack (TIA) should be treated with oral anticoagulation (OAC), preferably with a novel agent (NOAC). Whether these recommendations are adhered in clinical practice is not well defined. Purpose(s): We examined the patterns and rates of OAC use and reasons for use of NOAC agents vs. warfarin among AF patients with a history of stroke/TIA. Method(s): Phase-II of the Stroke Prevention and Rhythm INTerventions in Atrial Fibrillation (SPRINT-AF) registry prospectively enrolled 2,499 patients with nonvalvular AF at 132 sites in Canada (Nov 2013 to March 2016). We report on data from the first 2,215 patients enrolled. Eligibility criteria included documented AF within the past 10 years, absence of a non-AF indication for oral anticoagulation (OAC), and informed consent. Patients were seen in study follow-up at baseline and 3 months, and underwent centralized follow-up at 6 and 12 months. Result(s): There were 261 (11.8%) patients with a history of stroke/TIA at baseline. Patients with a history of stroke/TIA (vs. without) were older (76.7+/-8.8 vs. 73.1+/-10.7 years, p<0.001), more likely to have heart failure (19.9 vs. 11.7%, p<0.001), previous myocardial infarction (23.8 vs. 13.3%, p<0.001) and coronary artery bypass surgery (16.1 vs. 6.9%, p<0.001). Among patients with a prior history of stroke or TIA, 237 (90.8%) were treated with OAC. After adjustment of baseline characteristics with multivariable logistic regression, a history of stroke/TIA was associated with increased OAC use (odds ratio 2.0, 95% CI 1.3 to 3.1). Of patients treated with OAC, 2 out of 3 were treated with a NOAC agent (69%). After multivariable logistic regression, age, sex, hypertension, diabetes, heart failure, vascular disease, history of intracranial bleeding, and concomitant antiplate- let use were not associated with NOAC vs. warfarin use. Of the 23 (8.8%) patients who were not anticoagulated, the most common reason for not prescribing an OAC included: physician-perceived elevated bleeding risk (57%), advanced age (17%), patient refusal (13%), high risk of falls (9%), and frailty (9%). In this subgroup, 4 (17%) patients were started on OAC after the baseline visit. Conclusion(s): In this high-risk patient population, this contemporary Canadian prospective AF registry demonstrated excellent compliance with guideline recommendations on anticoagulation for stroke prevention. Most patients were treated with a NOAC agent instead of warfarin.