Andrea Gerth

Anticoagulation using vitamin K antagonists (VKAs) significantly reduces the risk of recurrent stroke in stroke patients with atrial fibrillation (AF) and is recommended by guidelines. The German Competence NETwork on Atrial Fibrillation established a nationwide prospective registry including 9,574 AF patients, providing the opportunity to analyse AF management according to German healthcare providers. On enrolment, 896 (9.4 %) patients reported a prior ischaemic stroke or transient ischaemic attack. Stroke patients were significantly older, more likely to be female, had a higher rate of cardiovascular risk factors, and more frequently received anticoagulation (almost exclusively VKA) than patients without prior stroke history. Following enrolment, 76.4 % of all stroke patients without VKA contraindications received anticoagulation, which inversely associated with age (OR 0.95 per year; 95 % CI 0.92–0.97). General practitioners/internists (OR 0.40; 95 % CI 0.21–0.77) and physicians working in regional hospitals (OR 0.47; 95 % CI 0.29–0.77) prescribed anticoagulation for secondary stroke prevention less frequently than physicians working at university hospitals (reference) and office-based cardiologists (OR 1.40; 95 % CI 0.76–2.60). The impact of the treating healthcare provider was less evident in registry patients without prior stroke. In the AFNET registry, anticoagulation for secondary stroke prevention was prescribed in roughly three-quarters of AF patients, a significantly higher rate than in primary prevention. We identified two factors associated with withholding oral anticoagulation in stroke survivors, namely higher age and—most prominently—treatment by a general practitioner/internist or physicians working at regional hospitals.

Vorhofflimmern (VHF) ist die häufigste anhaltende Rhythmusstörung in der täglichen Praxis und trägt ein ca. fünffach erhöhtes Risiko für einen ischämischen Schlaganfall. Um ein aktuelles Abbild von Diagnostik und Behand-lung sowie von langfristigen Komplikationen und Prognose von Patienten mit VHF in Deutschland zu erhalten, wurde 2003 im Kompetenznetz Vorhofflimmern ein Patientenregister etabliert. Erste Ergebnisse weisen daraufhin, dass die Rate der oralen Anti-koagulation mit 67% mit den Ergebnissen anderer europäischer Register vergleichbar ist. Insbesondere ältere Patienten (ab dem 70. Lebensjahr) werden nicht ausreichend mit einer erforderlichen oralen Antikoagulation behandelt. Die klinisch übliche Risikostratifizierung nach dem CHADS₂-Score hat in der klinischen Praxis nur einen limitierten Einfluss auf die Entscheidung zur Antikoagulation. Unterschiedliche Antikoagulationsraten in spezialisierten Zentren gegenüber nicht kardiologischen Einrichtungen sind nur zum Teil durch Unterschiede in Altersstruktur und Begleiterkrankungen zu erklären. Entsprechend wird die Antikoagulation bei VHF zur Prävention ischämischer Schlaganfälle weiter unzureichend genutzt. Atrial fibrillation is the most common clinically relevant arrhythmia and carries a fivefold increase in embolic stroke risk. In order to obtain an impression of current diagnostic and therapeutic decisions as well as long term complications and prognosis in patients with atrial fibrillation in Germany, a patient registry was established in 2003 within the German AFNET. Initial results indicate that the overall rate of oral anticoagulation is comparable to results from other registries on atrial fibrillation in Europe. Most notably, patients aged 70 years and older frequently do not receive a required oral anticoagulation. The clinical stroke risk stratification scheme, CHADS₂-score, has only a minor impact on the decision to provide anticoagulation in daily clinical practice. The observed differences in anticoagulation rate in specialized cardiac care centres as compared to non-specialized centres could only be in part explained by differences in age of the patients and concomitant health conditions. It is concluded that oral anticoagulation remains underused in the prevention of ischemic stroke in atrial fibrillation in Germany.