title: Rates and Determinants of 5-Year Outcomes After Atrial Fibrillation-Related Stroke: A Population Study.
abstract: OBJECTIVE
  Demographic trends in atrial fibrillation (AF) incidence may yield a substantial rise in the societal burden of AF-related stroke (AF-stroke). Accurate population-wide outcome data are essential to inform health service planning to improve AF-stroke prevention, and provision of rehabilitation, nursing home, and community supports for AF-stroke survivors.
  
  
  METHODS
  We investigated rates and determinants of 5-year fatality, stroke recurrence, functional outcomes, and prescribing of secondary prevention medications in AF-stroke in the North Dublin Population Stroke Study. Ascertainment included hot and cold pursuit using multiple overlapping sources. Survival analysis was performed using lifetables and Kaplan-Meier survival curves, and Cox proportional hazard modeling was performed to identify predictors of death and recurrent stroke.
  
  
  RESULTS
  Five hundred sixty-eight patients with new stroke were identified, including 177 (31.2%) AF-stroke. At 5 years, 39.2% (confidence interval, 31.5-46.8) of ischemic AF-stroke patients were alive. Congestive heart failure, hypertension, age <65, 65-74 years, and ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack or thromboembolism, vascular disease and female sex (CHA2DS2-VASc) score (hazard ratio [HR], 1.34; P<0.001), CHADS2 score (HR 1.42, P=0.004), National Institute of Health Stroke Scale (HR, 1.09; P<0.0001), and subtherapeutic international normalized ratio (<2.0) at stroke onset (HR, 3.29; P=0.003) were independently associated with 5-year fatality, whereas warfarin (HR, 0.40; P=0.001) and statin use after index stroke (HR, 0.52; P=0.005) were associated with improved survival. The 5-year recurrence rate after ischemic AF-stroke was 21.5% (confidence interval, 14.5-31.3). Trends toward greater risk of recurrence were observed for persistent AF (HR, 3.09; P=0.07) and CHA2DS2-VASc score (HR, 1.34; P=0.07). Nursing home care was needed for 25.9% of patients.
  
  
  CONCLUSIONS
  AF-stroke is associated with considerable long-term morbidity, fatality, stroke recurrence, and nursing home requirement. Adequately resourced national AF strategies to improve AF detection and prevention are needed.
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.). dhayden@mater.ie.
authors.forename: Derek T
authors.initials: DT
authors.lastname: Hayden
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Niamh
authors.initials: N
authors.lastname: Hannon
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Callaly
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Danielle
authors.initials: D
authors.lastname: Ní Chróinín
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Gillian
authors.initials: G
authors.lastname: Horgan
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Lorraine
authors.initials: L
authors.lastname: Kyne
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Joseph
authors.initials: J
authors.lastname: Duggan
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Eamon
authors.initials: E
authors.lastname: Dolan
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Killian
authors.initials: K
authors.lastname: O'Rourke
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: David
authors.initials: D
authors.lastname: Williams
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Sean
authors.initials: S
authors.lastname: Murphy
authors.affiliation: From the Stroke Department (D.T.H., E.C., D.N.C., G.H., K.O., S.M., P.J.K.), and Geriatrics Department (L.K., J.D.), Neurovascular Unit for Applied Translational Research and Therapeutics, University College Dublin/Dublin Academic Medical Centre, Mater University Hospital, Dublin, Ireland; Stroke Department, Beaumont University Hospital, Dublin, Ireland (D.W.); Stroke Department, Connolly Hospital Blanchardstown, Dublin, Ireland (E.C., E.D.); Department of Neurosciences, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom (N.H.); and Stroke Department, Royal College of Surgeons, Dublin, Ireland (D.W., S.M.).
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kelly
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis* / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007494:Ireland / Q000453:epidemiology; D008297:Male; D011159:Population Surveillance; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome
keywords: atrial fibrillation; nursing homes; rehabilitation; stroke; survival