Evaluation of risk factors and drug adherence in the occurrence of stroke in patients with atrial fibrillation

Main Article Content

Keywords

Atrial Fibrillation, Stroke, Inpatients, Risk Factors, Anticoagulants, Medication Adherence, Hypertension, Coronary Disease, Obesity, Odds Ratio, Logistic Models, Case-Control Studies, Lebanon

Abstract

Background: Atrial fibrillation (AF) patients are at high risk of developing a stroke and anticoagulant medications are generally prescribed to prevent stroke in AF population.


Objective: This study aims to evaluate stroke risk factors among hospitalized patients with AF and to assess the level of adherence to medications in AF patients and their relation with stroke.


Methods: This is a case-control study conducted between June 1st, 2018 and December 31th, 2018 among AF patients admitted to seven tertiary Lebanese hospitals. Data were collected using a standardized questionnaire. Adherence to medications was assessed using the Lebanese Medication Adherence Scale-14. Odds ratios (OR) expressed the strength of association between the independent variables and the dependent variable and were estimated using unconditional logistic regression adjusted for confounding factors. P<0.05 determined statistical significance.


Results: In total, 174 cases of AF patients were included with 87 cases and 87 controls. The risk of stroke among AF significantly increased with the presence of a history of hypertension, aOR 16.04 (95%CI, 2.27-113.37; p=0.005), history of coronary heart disease/myocardial infarction, and history of obesity. Anticoagulant medication significantly decreased the risk of stroke among AF patients, aOR 0.27 (95%CI, 0.07-0.98; P=0.047). High adherence to medications was significantly associated with a reduced risk of stroke, aOR 0.04 (95%CI, 0.01-0.23; p<0.001).


Conclusions: Having a history of hypertension is one of the strongest risk factors for stroke among AF patients in Lebanon. While anticoagulant medication use was associated with a reduced risk for stroke, high adherence to medications is critical for stroke prevention. Public health interventions are needed to tackle low-adherence to medication and prevent stroke among AF patients.

Abstract 814 | pdf Downloads 376

References

1. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol. 1988;41(2):105‐114. https://doi.org/10.1016/0895-4356(88)90084-4
2. El-Hajj M, Salameh P, Rachidi S, Hosseini H. The epidemiology of stroke in the Middle East. Eur Stroke J. 2016;1(3):180‐198. https://doi.org/10.1177/2396987316654338
3. El-Hajj M, Salameh P, Rachidi S, Al-Hajje A, Lahoud N, Hosseini H. Stroke Risk Factors: A Hospital-Based Case-Control Study in Lebanon. J R Soc Med. 2017:8(6):1-10. https://doi.org/10.1177/2054270417713692
4. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983‐988. https://doi.org/10.1161/01.str.22.8.983
5. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JV, Pearson TA; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council for High Blood Pressure Research,; Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2011 Feb;42(2):e26]. Stroke. 2011;42(2):517‐584. https://doi.org/10.1161/str.0b013e3181fcb238
6. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893‐2962. https://doi.org/10.1093/eurheartj/ehw210
7. Singer DE, Chang Y, Fang MC, Borowsky LH, Pomernacki NK, Udaltsova N, Go AS. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med. 2009;151(5):297‐305. https://doi.org/10.7326/0003-4819-151-5-200909010-00003
8. Abraham NS, Singh S, Alexander GC, Heien H, Haas LR, Crown W, Shah ND. Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study. BMJ. 2015;350:h1857. https://doi.org/10.1136/bmj.h1857
9. Chang HY, Zhou M, Tang W, Alexander GC, Singh S. Risk of gastrointestinal bleeding associated with oral anticoagulants: population based retrospective cohort study. BMJ. 2015;350:h1585. https://doi.org/10.1136/bmj.h1585
10. De Geest S, Sabaté E. Adherence to long-term therapies: evidence for action. Eur J Cardiovasc Nurs. 2003;2(4):323. https://doi.org/10.1016/s1474-5151(03)00091-4
11. Urquhart J. The odds of the three nons when an aptly prescribed medicine isn't working: non-compliance, non-absorption, non-response. Br J Clin Pharmacol. 2002;54(2):212‐220. https://doi.org/10.1046/j.1365-2125.2002.01629.x
12. van Walraven C, Hart RG, Connolly S, Austin PC, Mant J, Hobbs FD, Koudstaal PJ, Petersen P, Perez-Gomez F, Knottnerus JA, Boode B, Ezekowitz MD, Singer DE. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke. 2009;40(4):1410‐1416. https://doi.org/10.1161/strokeaha.108.526988
13. Emren SV, Şenöz O, Bilgin M, Beton O, Aslan A, Taşkin U, Açiksari G, Asarcikli LD, Çakir H, Bekar L, Bolat İ, Yayla Ç, Çelebi B, Dalgiç O, Çelik O, Şafak Ö, Akyel S, Güngör H, Düzel B, Zoghi M. Drug Adherence in Patients With Nonvalvular Atrial Fibrillation Taking Non-Vitamin K Antagonist Oral Anticoagulants in Turkey: NOAC-TR. Clin Appl Thromb Hemost. 2018;24(3):525‐531. https://doi.org/10.1177/1076029617693940
14. Mazurek M, Shantsila E, Lane DA, Wolff A, Proietti M, Lip GYH. Secondary Versus Primary Stroke Prevention in Atrial Fibrillation: Insights From the Darlington Atrial Fibrillation Registry. Stroke. 2017;48(8):2198‐2205. https://doi.org/10.1161/strokeaha.116.016146
15. Bou Serhal R, Salameh P, Wakim N, Issa C, Kassem B, Abou Jaoude L, Saleh N. A New Lebanese Medication Adherence Scale: Validation in Lebanese Hypertensive Adults. Int J Hypertens. 2018;2018:3934296. https://doi.org/10.1155/2018/3934296
16. World Health Organization. Physical activity. Available at: https://www.who.int/news-room/fact-sheets/detail/physical-activity (accessed Jul 1, 2019).
17. Cambeiro G, Cristina M, Mañero R, Moisés, Roubin R, Assi A, Emad, Sergio, Juanatey G, Ramón J. Review Of Obesity And Atrial Fibrillation: Exploring The Paradox. J Atr Fibrillation. 2015;8(2):1259. https://doi.org/10.4022/jafib.1259
18. Khoury M, Jazra C. Why a special issue on atrial fibrillation? J Med Liban. 2013:61(2):67. https://doi.org/10.12816/0000403
19. Stroke Risk in Atrial Fibrillation Working Group. Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology. 2007;69(6):546‐554. https://doi.org/10.1212/01.wnl.0000267275.68538.8d
20. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994;154(13):1449‐1457. https://doi.org/10.1001/archinte.1994.00420130036007
21. Steensig K, Olesen KKW, Thim T, Nielsen JC, Jensen SE, Jensen LO, Kristensen SD, Bøtker HE, Lip GYH, Maeng M. CAD Is an Independent Risk Factor for Stroke Among Patients With Atrial Fibrillation. J Am Coll Cardiol. 2018;72(20):2540‐2542. https://doi.org/10.1016/j.jacc.2018.08.1046
22. El-Hajj M, Salameh P, Rachidi S, Al-Hajje A, Hosseini H. Development of a risk of stroke score in the Lebanese population. Clin Epidemiol Glob Health. 2019;7(1);88-97. https://doi.org/10.1016/j.cegh.2018.02.003
23. Heart and Stroke Foundation of Canada. Stroke best practices. Available at: http://www.strokebestpractices.ca (accessed Jun 1, 2019).
24. Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE, Shea S, Paik MC, Hauser WA. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998;147(3):259‐268. https://doi.org/10.1093/oxfordjournals.aje.a009445
25. Degli Esposti L, Saragoni S, Benemei S, Batacchi P, Geppetti P, Di Bari M, Marchionni N, Sturani A, Buda S, Degli Esposti E. Adherence to antihypertensive medications and health outcomes among newly treated hypertensive patients. Clinicoecon Outcomes Res. 2011;3:47‐54. https://doi.org/10.2147/ceor.s15619
26. Mayor S. Non-adherence to medication increases stroke risk in patients with high blood pressure. BMJ. 2013;347:f4586. https://doi.org/10.1136/bmj.f4586
27. Al-Hajje A, Awada S, Rachidi S, Zein S, Bawab W, El-Hajj Z, Zeid MB, Yassine M, Salameh P. Factors affecting medication adherence in Lebanese patients with chronic diseases. Pharm Pract (Granada). 2015;13(3):590. https://doi.org/10.18549/pharmpract.2015.03.590
28. Mroueh L, Ayoub D, El-Hajj M, Awada S, Rachidi S, Zein S, Al-Hajje A. Evaluation of medication adherence among Lebanese diabetic patients. Pharm Pract (Granada). 2018;16(4):1291. https://doi.org/10.18549/pharmpract.2018.04.1291
29. Moser M. World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension-Do These Differ From the U.S. Recommendations? Which Guidelines Should the Practicing Physician Follow?. J Clin Hypertens (Greenwich). 1999;1(1):48‐54.
30. Matar D, Frangieh AH, Abouassi S, Bteich F, Saleh A, Salame E, Kassab R, Azar RR. Prevalence, awareness, treatment, and control of hypertension in Lebanon. J Clin Hypertens (Greenwich). 2015;17(5):381‐388. https://doi.org/10.1111/jch.12485

Most read articles by the same author(s)