Clinical epidemiology of atrial fibrillation and related cerebrovascular events in the United States.
ABSTRACT Atrial fibrillation (AF) is an important, independent risk factor for stroke and is estimated to cause a 5-fold increase in ischemic stroke risk. The aim of this article is to describe the changing epidemiology of AF in the United States and to assess the implications for stroke prevention and treatment.
AF prevalence is increasing in the general population. This is likely due to the aging of the population, the improvements in coronary care and the rising prevalence of AF risk factors such as diabetes. Risk factors such as rheumatic heart disease and hypertension have decreased in prevalence over the past few decades. However, novel risk factors such as obesity and possibly the metabolic syndrome have been identified and these have the potential to further increase AF prevalence. The utilization of warfarin has improved and this is reflected in falling ischemic stroke rates in the AF population. There is evidence for an increased incidence of anticoagulant associated intraparenchymal hemorrhages during the 1990s.
Although the decline in stroke rates in AF is laudable, the rising prevalence of AF, the changing profile of risk factors, and the recent plateauing of warfarin use indicate that stroke in AF patients will continue to be a significant public health problem.
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ABSTRACT: Nonvalvular atrial fibrillation increases in prevalence with age and often requires long-term oral anticoagulation to prevent ischemic stroke. Vitamin K antagonists are highly effective for stroke prevention. However, suboptimal risk assessment, variability in response, drug and food interactions, and monitoring requirements result in underprescription of warfarin by physicians and poor adherence to therapy by patients. In addition, the vitamin K antagonists modulate coagulation by inhibiting multiple coagulation factors (factors II, VII, IX, and X). New oral direct factor IIa and Xa inhibitors offer improved risk-benefit profiles, simplifying thromboprophylaxis and overcoming some practical barriers to long-term therapy. Their potential benefit is a function of targeting specific activated factors produced at key junctions of the coagulation system. However, important questions about patient management with these new agents have not been fully answered by studies completed to date and clinical inertia must yet be overcome. Mt Sinai J Med 79:705-720, 2012. © 2012 Mount Sinai School of Medicine.Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 11/2012; 79(6):705-20. DOI:10.1002/msj.21346 · 1.56 Impact Factor
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ABSTRACT: Warfarin use has rapidly increased with the aging of the population. We investigated the temporal trends in the incidence and outcome of warfarin-related intracerebral hemorrhages (ICHs) in a defined population. We identified all subjects with first-ever primary ICH during 1993 to 2008 among the population of Northern Ostrobothnia, Finland. The number of warfarin users was obtained from the national register of prescribed medicines kept by the Social Insurance Institution of Finland. We calculated the annual incidence of warfarin-related ICHs, 28-day case fatality, and deaths from the primary bleed. The proportion of warfarin users among the population increased 3.6-fold from 0.68% in 1993 to 2.28% in 2008. Of a total of 982 patients with ICH, 182 (18.5%) had warfarin-related ICH. One-year survival rate after onset of stroke was 35.2% among warfarin users and 67.9% among nonusers. The annual incidence (P=0.062) and 28-day case fatality of warfarin-related ICHs (P=0.002) decreased during the observation period. Warfarin users were older (mean difference 6.6; 95% CI, 5.0 to 8.1; P<0.001) than nonusers. Admission international normalized ratio values above the therapeutic range (2.0 to 3.0) decreased through the observation period, suggesting improved control of anticoagulant therapy over time. The annual incidence and case fatality of warfarin-related ICHs decreased, although the proportion of warfarin users almost quadrupled in our population.Stroke 07/2011; 42(9):2431-5. DOI:10.1161/STROKEAHA.111.615260 · 6.02 Impact Factor