Higher Risk of Ischemic Events in Secondary Prevention for Patients With Persistent Than Those With Paroxysmal Atrial Fibrillation

Masatoshi Koga; Sohei Yoshimura; Yasuhiro Hasegawa; Satoshi Shibuya; Yasuhiro Ito; Hideki Matsuoka; Kazuhiro Takamatsu; Kazutoshi Nishiyama; Kenichi Todo; Kazumi Kimura; Eisuke Furui; Tadashi Terasaki; Yoshiaki Shiokawa; Kenji Kamiyama; Shunya Takizawa; Satoshi Okuda; Yasushi Okada; Tomoaki Kameda; Yoshinari Nagakane; Yoshiki Yagita; Kazuomi Kario; Masayuki Shiozawa; Shoichiro Sato; Hiroshi Yamagami; Shoji Arihiro; Kazunori Toyoda; SAMURAI Study Investigators

doi:10.1161/STROKEAHA.116.013746

Higher Risk of Ischemic Events in Secondary Prevention for Patients With Persistent Than Those With Paroxysmal Atrial Fibrillation

Stroke. 2016 Oct;47(10):2582-8. doi: 10.1161/STROKEAHA.116.013746. Epub 2016 Aug 16.

Authors

Masatoshi Koga¹, Sohei Yoshimura², Yasuhiro Hasegawa², Satoshi Shibuya², Yasuhiro Ito², Hideki Matsuoka², Kazuhiro Takamatsu², Kazutoshi Nishiyama², Kenichi Todo², Kazumi Kimura², Eisuke Furui², Tadashi Terasaki², Yoshiaki Shiokawa², Kenji Kamiyama², Shunya Takizawa², Satoshi Okuda², Yasushi Okada², Tomoaki Kameda², Yoshinari Nagakane², Yoshiki Yagita², Kazuomi Kario², Masayuki Shiozawa², Shoichiro Sato², Hiroshi Yamagami², Shoji Arihiro², Kazunori Toyoda²; SAMURAI Study Investigators

Affiliations

¹ From the Division of Stroke Care Unit (M.K., S.A.), Department of Cerebrovascular Medicine (S.Y., M.S., S. Sato, K. Toyoda), and Department of Neurology (H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, South Miyagi Medical Center, Ogawara, Japan (S. Shibuya); Department of Neurology, Toyota Memorial Hospital, Toyota, Japan (Y.I.); Department of Cerebrovascular Medicine, NHO Kagoshima Medical Center, Kagoshima, Japan (H.M.); Department of Neurology, Ohta Memorial Hospital, Fukuyama, Japan (K. Takamatsu); Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan (K.N.); Department of Neurology, Kobe City Medical Center General Hospital, Japan (K. Todo); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura, Y.Y.); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan (T.T.); Departments of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Neurology, Tokai University School of Medicine, Isehara, Japan (S.T.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology and Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.); Division of Neurology (T.K.) and Division of Cardiovascular Medicine (K. Kario), Jichi Medical University School of Medicine, Shimotsuke, Japan; and Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan (Y.N.). [email protected].
² From the Division of Stroke Care Unit (M.K., S.A.), Department of Cerebrovascular Medicine (S.Y., M.S., S. Sato, K. Toyoda), and Department of Neurology (H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, South Miyagi Medical Center, Ogawara, Japan (S. Shibuya); Department of Neurology, Toyota Memorial Hospital, Toyota, Japan (Y.I.); Department of Cerebrovascular Medicine, NHO Kagoshima Medical Center, Kagoshima, Japan (H.M.); Department of Neurology, Ohta Memorial Hospital, Fukuyama, Japan (K. Takamatsu); Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan (K.N.); Department of Neurology, Kobe City Medical Center General Hospital, Japan (K. Todo); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura, Y.Y.); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan (T.T.); Departments of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Neurology, Tokai University School of Medicine, Isehara, Japan (S.T.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology and Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.); Division of Neurology (T.K.) and Division of Cardiovascular Medicine (K. Kario), Jichi Medical University School of Medicine, Shimotsuke, Japan; and Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan (Y.N.).

PMID: 27531346
DOI: 10.1161/STROKEAHA.116.013746

Abstract

Background and purpose: The discrimination between paroxysmal and sustained (persistent or permanent) atrial fibrillation (AF) has not been considered in the approach to secondary stroke prevention. We aimed to assess the differences in clinical outcomes between mostly anticoagulated patients with sustained and paroxysmal AF who had previous ischemic stroke or transient ischemic attack.

Methods: Using data from 1192 nonvalvular AF patients with acute ischemic stroke or transient ischemic attack who were registered in the SAMURAI-NVAF study (Stroke Management With Urgent Risk-Factor Assessment and Improvement-Nonvalvular AF; a prospective, multicenter, observational study), we divided patients into those with paroxysmal AF and those with sustained AF. We compared clinical outcomes between the 2 groups.

Results: The median follow-up period was 1.8 (interquartile range, 0.93-2.0) years. Of the 1192 patients, 758 (336 women; 77.9±9.9 years old) and 434 (191 women; 77.3±10.0 years old) were assigned to the sustained AF group and paroxysmal AF groups, respectively. After adjusting for sex, age, previous anticoagulation, and initial National Institutes of Health Stroke Scale score, sustained AF was negatively associated with 3-month independence (multivariable-adjusted odds ratio, 0.61; 95% confidence interval, 0.43-0.87; P=0.006). The annual rate of stroke or systemic embolism was 8.3 and 4.6 per 100 person-years, respectively (multivariable-adjusted hazard ratio, 1.95; 95% confidence interval, 1.26-3.14) and that of major bleeding events was 3.4 and 3.1, respectively (hazard ratio, 1.13; 95% confidence interval, 0.63-2.08).

Conclusions: Among patients with previous ischemic stroke or transient ischemic attack, those with sustained AF had a higher risk of stroke or systemic embolism compared with those with paroxysmal AF.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01581502.

Keywords: atrial fibrillation; hemorrhage; secondary prevention; stroke; thromboembolism.

Publication types

Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Anticoagulants / therapeutic use
Atrial Fibrillation / complications*
Brain Ischemia / complications
Brain Ischemia / epidemiology*
Brain Ischemia / prevention & control
Female
Follow-Up Studies
Humans
Incidence
Ischemic Attack, Transient / complications
Ischemic Attack, Transient / epidemiology*
Ischemic Attack, Transient / prevention & control
Male
Prospective Studies
Risk
Secondary Prevention
Stroke / complications
Stroke / epidemiology*
Stroke / prevention & control
Treatment Outcome
Warfarin / therapeutic use

Substances

Anticoagulants
Warfarin

Associated data

ClinicalTrials.gov/NCT01581502