Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trialBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3653 (Published 23 June 2011) Cite this as: BMJ 2011;342:d3653
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Illustrative results in this area would be the results of the series of
Bejot Y and Ben Salem D in Dijon (France) from 1985 to 2006.
Incidence rates, risk factors, prestroke treatment and survival in
cardioembolic stroke/AF (CE/AF) were studies from a prospective
population-based cohort from 1985 to 2006.
572 CE/AF patients from a total of 3,064 ischemic strokes were recorded:
.Determinant data were higher prevalence of previous AF patients aged
> 70 years and previous myocardial infraction in CE/AF stroke
.Hypercholesterolemia was more prevalent in other ischemic strokes.
The general tendency was a decrease in incidence over the 22 years (IR
ratio 0.9858, 95% CI 0.97 - 0.99, p= 0.03).
A significant increase in the use of anticoagulants and antiplatelet drugs
was noted (mainly in CE/AF strokes with previous AF). The conclusion of
the study was that the use of such treatment will have to increase
considering expected aging in future years.
Survival descriptors were 72% at 1 month, 52% at 1 year and 43%
at 2 years (lower than those of other ischemic stroke types ).
This area-approach has been validated in previous regional studies such as the one performed by Calleja S et al in Asturias, where a
sectional sample from 2003 to 2004 in older people with stroke (> 80 years) confirmed that cardioembolic pathology was found in 54.7% of the
cases (embolic arrhythmias: 35% of the ECG and 50% of the Holter studies), whereas 12.5% of the cases presented anticoagulant treatment
and 40.3% with antiagregant treatment. Recurrent ictus was about 20.8% of
the cases, and 56% presented with cardioembolic stroke (P= 0.041).
Regarding in-patient mortality, the series by H del Mar and H Vall d'Hebron in 1,678 patients with first ischemic stroke showed a
gender difference between age-groups: 4.9 % in < 75 years and 16.1%
in > 75 years (women) versus 5.7% in < 75 years and 19.9% in
> 75 years (men).
Considering district areas, the series with AF in subjects > 85
years described figures of 40.6 & vs 25.3% and cardioembolic stroke
(36.6% vs 16.9% ) (Garraf).
-Bejot V et al. Epidemiology of ischemic stroke from AF in Dijon, France, from 1985 to 2006. Neurology 2009. January 27
-Roquer J et al. AF and in-patient mortality in subjects with first ischemic stroke. SEN 2005
-Calleja S. Epidemiologic study of stroke in older people (> 80 years). SEN 2005
Competing interests: No competing interests
In their paper, Hobbs and al. (1) confirm the efficacy of vitamin K
antagonist to reduce the risk of stroke, particularly in older patients
with atrial fibrillation (AF). Unfortunaltely, in routine practice, less
than half of elderly patients deemed eligible for AVK actually receive it.
Our hypothesis was that geriatric characteristics (functional impairment,
cognitive disorders, malnutrition, risk for falls, depression) could be an
explanation of the underprescription of AVK for old patients with AF. We
analyzed retrospectively 768 consecutive geriatric patients admitted in an
acute geriatric unit of an academic hospital; 14% presented chronic atrial
fibrillation and forty nine percents of them did not receive any AVK
treatment at admission. The proportions of geriatric problems
(cognitive, malnutrition, depression and falls) did not differ between the
groups. To determine whether the decision of AVK therapy before admission
has been influenced by the risk of an embolic stroke defined for patients
with a high CHADS (congestive heart failure, hypertension, age older than
75 years, diabetes, and previous stroke) score, we compared the
proportions of those conditions between the groups: there were no
differences of proportions of patients who fulfilled those conditions
between the groups.
Almost the half of the patients presenting AF did not receive any
anticoagulation therapy before admission. Geriatric characteristics did
not represent barriers to AVK use. Few data are available to suggest that
assessment of geriatric characteristics should be include in the decision
process for treating the patients. For example, the use of antithrombotic
agents and falls are independently associated with an increased risk of
hemorrhagic injury. However, few studies have delineated the risk of fall-
related hemorrhagic complications in persons who are taking antithrombotic
therapy. In the study of Bond et al., compared with persons taking no
antithrombotic therapy, those taking AVK had lower rates of fall-related
hemorrhagic injuries. The absolute rate of the development of fall-related
intracranial hemorrhagic injury such as subdural hematomas was low, even
in persons taking AVK. These counter- intuitive results may be due to
selection bias, and suggest that physicians are very conservative in
selecting patients for AVK therapy, choosing only those who are
sufficiently healthy to be at much lower than average risk of suffering
fall-related hemorrhagic injuries. This phenomenon may lead to physicians
overestimating the potential for fall-related major hemorrhagic injury in
persons taking antithrombotic therapy, with the possible denial of AVK
therapy to many of those who would benefit. This perception may contribute
to the care gap between the number of patients who would theoretically
derive overall benefit from AVK therapy and those who are actually
receiving it. Moreover a physician's experience with bleeding events
associated with AVK can influence prescribing AVK. Adverse events that are
possibly associated with underuse of AVK may not affect subsequent
The reasons for this low use of AVK remain unclear despite the
availability of multiple physician surveys investigating thebarriers to
the prescription of AVK. More research is needed to identify and to
clarify the relative importance of patient-, physician-, and health care
(1) Hobbs FDR, Roalfe AK, Lip GYH, Fletcher K, Fitzmaureice DA, Mant
J. Performance of stroke risk scores in older peolple with atrial
fibrillation not taking warfarin: comparative cohort study from BAFTA
trial. BMJ 2011; 342:d3653 doi: 10.1136/bmj.d3653
(2) De Breucker S, Herzog G, Pepersack T. Could geriatric characteristics
explain the under-prescription of anticoagulation therapy for old patients
admitted with atrial fibrillation? Drugs Aging 2010;27:807-13
(3) Bond AJ, Molnar FJ, Li M, Mackey M, Man-Son-Hing M. The risk of
hemorrhagic complications in hospital in-patients who fall while
receiveing antithrombotic therpay. Thrombosis Journal 2005;3:1.
(4) Choudhry NK, Soumerai SB, Normand SL, Ross-Degnan D, Laupacis A,
Anderson GM. Warfarin prescribing in atrial fibrillation: the impact of
physician, patient, and hospital characteristics. Am Journal Medicine
Competing interests: No competing interests