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Research Letters | Jan 28, 2013

Temporal Trends in Ischemic Stroke and Anticoagulation Therapy Among Medicare Patients With Atrial Fibrillation:  A 15-Year Perspective (1992-2007)

Gautam R. Shroff, MBBS; Craig A. Solid, PhD; Charles A. Herzog, MD
JAMA Intern Med. 2013;173(2):159-160. doi:10.1001/jamainternmed.2013.1579.
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Atrial fibrillation (AF) is an independent, modifiable risk factor for ischemic stroke1 and independently associated with increased mortality.2 Nonvalvular AF is associated with a nearly 5-fold higher risk of ischemic stroke; this risk progressively increases with age.3 In a meta-analysis involving 29 clinical studies and 28 044 patients, judicious antithrombotic therapy with adjusted-dose warfarin was shown to reduce risk related to ischemic stroke by nearly 60% and mortality by approximately 25%, without significant increases in hemorrhagic stroke.4 However, diffusion of evidence-based knowledge from clinical trials into routine clinical practice demonstrates a significant time lag and evidence-to-practice gap; rates of ischemic stroke are therefore higher in clinical practice.5 We sought to extend previous work by Lakshminarayan et al6 to examine temporal trends in ischemic and hemorrhagic stroke rates and warfarin use in the Medicare population over a span of 15 years.
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Figure. Trends in ischemic and hemorrhagic stroke rates and warfarin use among patients with prevalent atrial fibrillation.

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Are the stroke rates age- and sex-adjusted?
Posted on January 3, 2013
Alvaro Alonso
Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
Conflict of Interest: None Declared
This research letter shows that among fee-for-service (FFS) Medicare enrollees with atrial fibrillation, there has been a decrease in stroke rates in parallel with an increase of warfarin use. In the discussion, the authors recognize the study limitations. One issue the authors did not clarify, however, was whether the age-specific stroke rates and warfarin use prevalence were standardized by age, sex, and race. As Piccini et al have recently shown (Piccini J, et al. Circ Cardiovasc Qual Outcomes 2012;5:85-93, PMID: 22235070), AF prevalence among FFS Medicare enrollees has increased over time, particularly among the elderly. Therefore, comparing rates in the early 90s with those in the 2000s might not make sense due to the differences in age distribution of AF patients. To be able to interpret these results appropriately, the authors should provide sociodemographic information on AF patients over time and report standardized rates, in addition or instead of crude rates. If the rates presented in the study are already standardized, that should be made clear.
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