Incidence of intracranial hemorrhage in patients with AF who are prone to fall

Yale University, New Haven, Connecticut, United States
The American Journal of Medicine (Impact Factor: 5). 07/2005; 118(6):612-7. DOI: 10.1016/j.amjmed.2005.02.022
Source: PubMed

ABSTRACT Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking.
Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes.
Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9-4.1) in patients at high risk for falls and 1.1 (1.0-1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3-3.1) in patients at high risk for falls and 0.34 (0.27-0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0-3.1) for neuropsychiatric disease, 2.1 (1.6-2.7) for prior stroke, and 1.9 (1.4-2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death.
Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.

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Available from: Martha J Radford, Sep 26, 2015
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    • "All incident NVAF patients without a history of ischemic stroke or major bleeding event were then followed for first ischemic stroke or major bleeding event using validated ICD-9 codes (Table 1) [14] [15] [16] [17]. Patients with events were matched with NVAF patients without events on age group at NVAF diagnosis, gender, race, geographic region, year of NVAF diagnosis, duration of enrollment, and warfarin use. "
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    ABSTRACT: Purpose. Acute healthcare utilization of stroke and bleeding has been previously examined among patients with nonvalvular atrial fibrillation (NVAF). The long-term cost of such outcomes over several years is not well understood. Methods. Using 1999-2009 Medicare medical and enrollment data, we identified incident NVAF patients without history of stroke or bleeding. Patients were followed from the first occurrence of ischemic stroke, major bleeding, or intracranial hemorrhage (ICH) resulting in hospitalization. Those with events were matched with 1-5 NVAF patients without events. Total incremental costs of events were calculated as the difference between costs for patients with events and matched controls for up to 3 years. Results. Among the 25,465 patients who experienced events, 94.5% were successfully matched. In the first year after event, average incremental costs were $32,900 for ischemic stroke, $23,414 for major bleeding, and $47,640 for ICH. At 3 years after these events, costs remained elevated by $3,156-$5,400 per annum. Conclusion. While the costs of stroke and bleeding among patients with NVAF are most dramatic in the first year, utilization remained elevated at 3 years. Cost consequences extend beyond the initial year after these events and should be accounted for when assessing the cost-effectiveness of treatment regimens for stroke prevention.
    Cardiology Research and Practice 10/2012; 2012(8):645469. DOI:10.1155/2012/645469
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    • "At the conclusion of the telephone educational session, the medically trained peer proceeded through a standardised patient pro forma, collecting de-identified information about patient demographics, stroke risk factors, other comorbidities, current antithrombotic medications, and issues relevant to anticoagulation use. Medically trained peers calculated the patient’s CHADS2 score with participating GPs, providing general feedback based on evidence-based guideline recommendations, according to patients’ CHADS2 scores [24]. The CHADS2 score assigns two points for prior stroke or TIA and one point each for the following risk factors: congestive heart failure, history of hypertension, age over 75, and diabetes. "
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    ABSTRACT: Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke. The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this 'distance education' program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit. The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management. Australian Clinical Trials Registry Registration Number: ACTRN12611000076976.
    Implementation Science 07/2012; 7:63. DOI:10.1186/1748-5908-7-63 · 4.12 Impact Factor
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    • "The recent Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial [25] showed that even in an older AF patient group, warfarin decreased fatal stroke (1.8% per yr vs. 3.8% per year), and did not increase intracranial hemorrhage risk (1.4% per year vs. 1.6% per year) compared to aspirin therapy. Moreover, Gage et al [24] demonstrated that while older patients are at high risk for falls and carry an increased risk for intracranial hemorrhage, these patients also have a higher stroke risk, and therefore would likely benefit from anticoagulant therapy. These studies emphasize the point that fear of intracranial hemorrhage might be overestimated in this patient cohort. "
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    ABSTRACT: Atrial fibrillation affects an estimated 2.5 million Americans and incurs an average annual stroke risk of 4.5% per year. Despite warfarin reducing stroke risk by approximately 66%, prior studies show warfarin usage rates to be about 50%. However, the methods that define warfarin as "inappropriate underutilization" might not be sensitive enough to pick up relative contraindications. We assessed the inappropriate underutilization of warfarin in atrial fibrillation patients at our hospital by abstracting individual patient charts. Medical records were reviewed to determine stroke risk factors, warfarin use, and documented contraindications to warfarin use in 364 consecutive patients with atrial fibrillation. Amongst 364 atrial fibrillation patients, 54.6% received warfarin anticoagulation. Overall, 29.5 % of patients had documented reasons for not prescribing warfarin. Primary reasons listed by treating physicians included: gastrointestinal bleed 10.7%, secondary/transient atrial fibrillation 8.2%, and fall risk 6.3%. Only 7.1% of the patients had no documented reasons for the lack of warfarin use. Consistent with previous reports, 45.4% of patients in this atrial fibrillation cohort were not prescribed warfarin. However, after reviewing medical charts for documented reasons why warfarin was not used, the inappropriate underutilization rate was only 7.1%. These findings suggest that studies utilizing administrative database and ICD-9 CM coding might overestimate warfarin underutilization.
    Thrombosis Journal 06/2008; 6(1):6. DOI:10.1186/1477-9560-6-6 · 1.31 Impact Factor
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