Assessment of Trends in Guideline-Based Oral Anticoagulant Prescription for Patients With Ischemic Stroke and Atrial Fibrillation in China
Authors: Hong-Qiu Gu, Xin Yang, Chun-Juan Wang, Xing-Quan Zhao, Yi-Long Wang, Li-Ping Liu, Xia Meng, Yong Jiang, Hao Li, Chelsea Liu, Yun-Yun Xiong, Gregg C. Fonarow, David Wang, Ying Xian, Zi-Xiao Li, Yong-Jun Wang
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. <h3>Objective</h3> To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline–recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. <h3>Design, Setting, and Participants</h3> This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. <h3>Exposure</h3> Calendar year. <h3>Main Outcomes and Measures</h3> Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline–recommended prescribing of OACs (warfarin and non–vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. <h3>Results</h3> Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA<sub>2</sub>DS<sub>2</sub>-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]–vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (<i>P</i><sub> </sub>&lt; .001 for trend). Of 49 531 eligible patients (26 028 men [52.5%]; mean [SD] age, 73.4 [10.4] years), 20 390 (41.2%) had an OAC prescription at discharge, an increase from 23.2% (36 of 155) in the third quarter of 2015 to 47.1% (403 of 856) in the third quarter of 2019 (<i>P</i> &lt; .001 for trend). Warfarin was the most commonly prescribed OAC (11 956 [24.2%]) and had the largest temporal increase (from 5.8% [9 of 155] to 20.7% [177 of 856]). Older age (adjusted odds ratio [aOR] per 5 year increase, 0.89;95% CI, 0.89-0.90), lower levels of education (aOR for below elementary school, 0.84; 95% CI, 0.74-0.95 ), lower income (aOR for ≤¥1000 [$154], 0.66; 95% CI, 0.59-0.73), having new rural cooperative medical scheme insurance (aOR, 0.92; 95% CI, 0.87-0.96), prior antiplatelet use (aOR, 0.70; 95% CI, 0.66-0.74), having several cardiovascular comorbid conditions (including stroke or transient ischemic attack [aOR, 0.78; 95% CI, 0.75-0.82], hypertension [aOR, 0.84; 95% CI, 0.80-0.89], diabetes [aOR, 0.91; 95% CI, 0.83-0.99], dyslipidemia [aOR, 0.87; 95% CI, 0.80-0.94], carotid stenosis [aOR, 0.83; 95% CI, 0.69-0.98], and peripheral vascular disease [aOR, 0.80; 95% CI, 0.71-0.90]), and admission to secondary hospitals (aOR, 0.71; 95% CI, 0.68-0.74) or hospitals located in the central region of China (aOR, 0.80; 95% CI, 0.75–0.84) were associated with not being prescribed an OAC at discharge. <h3>Conclusions and Relevance</h3> This quality improvement study suggests that, despite significant improvement over time, OAC prescriptions remained low. Efforts to increase OAC prescriptions, especially non–vitamin K OACs, are needed for vulnerable subgroups by age, socioeconomic status, and presence of comorbid conditions.