Elsevier

American Heart Journal

Volume 162, Issue 4, October 2011, Pages 692-699.e2
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Improvement in use of anticoagulation therapy in patients with ischemic stroke: Results from Get With The Guidelines–Stroke

https://doi.org/10.1016/j.ahj.2011.07.019Get rights and content

Background

Anticoagulation therapy reduces thromboembolic events in patients with atrial fibrillation (AF) and has a class I indication for ischemic stroke patients with AF and no contraindications. We determined the patient and hospital level characteristics associated with an increased use of anticoagulation, including participation in the Get With The Guidelines–Stroke (GWTG-Stroke) Program.

Methods

We assessed the use of anticoagulation at hospital discharge in eligible AF patients with stroke or transient ischemic attack (TIA) at 1,354 participating hospitals between April 1, 2003, and April 1, 2010.

Results

Patients with AF (n = 197,778) represented 20.5% of patients with ischemic stroke/TIA. Among patients with AF, 47.6% (n = 94,119) were deemed eligible for anticoagulation, and of these, 94.0% were discharged on therapy. Older patients, African American or Hispanic patients, and those with diabetes were less likely to receive anticoagulation. Hospitals with a higher volume of patients with stroke were more likely to treat with anticoagulation. The Joint Commission Primary Stroke Centers were also more likely to treat eligible patients (odds ratio 2.16, 95% CI 1.82-2.56, P < .0001). From 2003 to 2010, contraindications to anticoagulation therapy declined from 69.7% to 28.4% (P < .0001 for trend). Anticoagulation among eligible patients improved from 88.4% to 95.2% (P < .0001) for 7 years of participation. Time in GWTG-Stroke was associated with improved anticoagulation use (adjusted odds ratio per year in program, 1.11, 95% CI 1.06-1.16, P < .001).

Conclusions

Use of anticoagulation among stroke patients with AF has increased to very high levels overall in GWTG-Stroke over time. Future efforts should focus on improving use among selected populations.

Section snippets

Methods

The methodology for the GWTG-Stroke quality improvement program has been described previously.8 Hospitals were recruited to participate over the course of the study. Patients were enrolled by querying the GWTG-Stroke database for demographic, clinical, and treatment data on consecutive patients presenting with ischemic stroke or TIA and AF. Between 2003 and 2007, patients were included if they had documented AF. In 2008, patients with atrial flutter were also included. Thus, patients with

Results

A total of 1,161,628 patients with stroke or TIA were entered into the GWTG-Stroke database between April 1, 2003, and April 1, 2010. Most (82.9%) were ischemic in nature. Of the patients with ischemic stroke or TIA (n = 962,940), AF was present in 197,778 (20.5%). There were 15,714 patients excluded because they were treated with comfort care measures only by the time of discharge. An additional 19,282 patients were excluded because they died, or were discharged to another acute care hospital

Discussion

In this cohort of patients with AF hospitalized with ischemic stroke or TIA from GWTG-Stroke, adherence to anticoagulation treatment guidelines increased over time, and the increase was achieved early and maintained over time. This study confirms previously published findings10 and extends the follow-up period to 6 years. Importantly, we show that the increase in anticoagulation treatment at discharge was not simply due to better documentation of contraindications but, rather, due to increasing

Conclusions

Data from the GWTG-Stroke quality improvement program demonstrate that improvement in anticoagulation initiation in patients with AF and ischemic stroke or TIA can be achieved early and maintained over time. This study demonstrates the highest rate of anticoagulation initiation in eligible patients compared with other quality improvement programs or patient cohorts with stroke.14, 15 Hospitals treating larger number of ischemic patients with stroke or those that are certified by TJC have higher

Acknowledgements

Funding/Support: The Get With The Guidelines–Stroke (GWTG-Stroke) Program is provided by the American Heart Association/American Stroke Association. The GWTG-Stroke Program is currently supported, in part, by a charitable contribution from Ortho-McNeil. The GWTG-Stroke has been funded in the past through support from Boeringher-Ingelheim, Merck, Bristol-Myers Squib/Sanofi Pharmaceutical Partnership, and the American Heart Association Pharmaceutical Roundtable.

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