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Multicenter Study
. 2016 Jun 13;5(6):e003408.
doi: 10.1161/JAHA.116.003408.

No Decline in the Risk of Stroke Following Incident Atrial Fibrillation Since 2000 in the Community: A Concerning Trend

Alanna M Chamberlain  1 , Robert D Brown Jr  2 , Alvaro Alonso  3 , Bernard J Gersh  4 , Jill M Killian  5 , Susan A Weston  5 , Véronique L Roger  6
Affiliations
Multicenter Study

No Decline in the Risk of Stroke Following Incident Atrial Fibrillation Since 2000 in the Community: A Concerning Trend

Alanna M Chamberlain et al. J Am Heart Assoc. .

Abstract

Background: While atrial fibrillation is a recognized risk factor for stroke, contemporary data on trends in stroke incidence after the diagnosis of atrial fibrillation are scarce.

Methods and results: Olmsted County, MN residents with incident atrial fibrillation or atrial flutter (collectively referred to as AF) from 2000 to 2010 were identified. Cox regression determined associations of year of AF diagnosis with ischemic stroke and transient ischemic attack (TIA) occurring through 2013. Among 3247 AF patients, 321 (10%) had an ischemic stroke/TIA over a mean of 4.6 years (incidence rate [95% CI] per 100 person-years: 2.14 [1.91-2.38]). Two hundred thirty-nine (7%) of 3265 AF patients experienced an ischemic stroke (incidence rate: 1.54 [1.35-1.75]). The risk of both outcomes remained unchanged over time after adjusting for demographics and comorbidities (hazard ratio [95% CI] per year of AF diagnosis: 1.00 [0.96-1.04] for ischemic stroke/TIA; 1.01 [0.96-1.06] for ischemic stroke only). In analyses restricted to patients with prescription information, the rates of anticoagulation use did not change over time, reaching 50.8% at 1 year after AF diagnosis. Further adjustment for anticoagulation use did not alter the temporal trends in stroke incidence (hazard ratio [95% CI] per year of AF diagnosis: 1.06 [0.97-1.15] for ischemic stroke/TIA; 1.08 [0.98-1.20] for ischemic stroke only).

Conclusions: Strokes/TIAs are frequent after AF, occurring in 10% of patients after 5 years of follow-up. The occurrence of stroke/TIA did not decline over the last decade, which may be influenced by a leveling off of anticoagulation use. This concerning trend has major public health implications.

Keywords: atrial fibrillation; ischemic stroke; temporal trends; transient ischemic attack.

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Figures

Figure 1
Figure 1
Exclusion criteria and final sample size used in the analysis for each outcome. AF indicates atrial fibrillation; BMI, body mass index; TIA, transient ischemic attack.
Figure 2
Figure 2
Smoothing splines of the association (hazard ratios [solid line] and 95% CI [dotted lines]) of calendar year of atrial fibrillation diagnosis with the risk of ischemic stroke or transient ischemic attack and ischemic stroke only. (A) Ischemic stroke or transient ischemic attack; (B) ischemic stroke only.
Figure 3
Figure 3
Cumulative incidence of ischemic stroke or transient ischemic attack and ischemic stroke only by year of atrial fibrillation diagnosis. (A) Ischemic stroke or transient ischemic attack; (B) ischemic stroke only. The cumulative incidence curves were adjusted for death as a competing event. AF indicates atrial fibrillation; TIA, transient ischemic attack.
Figure 4
Figure 4
Cumulative incidence of anticoagulant use by year of atrial fibrillation diagnosis. AF indicates atrial fibrillation.
Figure 5
Figure 5
Age‐ and sex‐adjusted predictors of ischemic stroke or transient ischemic attack and ischemic stroke only. (A) ischemic stroke or transient ischemic attack; (B) ischemic stroke only. COPD indicates chronic obstructive pulmonary disease; TIA, transient ischemic attack. The estimate for age is adjusted for sex and the estimate for sex is adjusted for age; all other estimates are adjusted for age and sex. HR indicates hazard ratio.
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