title: Use of Warfarin at Discharge Among Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation in China.
abstract: OBJECTIVE
  Guidelines recommend oral anticoagulation for ischemic stroke patients with atrial fibrillation, and previous studies have shown the underuse of anticoagulation for these patients in China. We sought to explore the underlying reasons and factors that currently affect the use of warfarin in China.
  
  
  METHODS
  From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with warfarin use at discharge.
  
  
  RESULTS
  Among the 952 acute ischemic stroke patients with nonvalvular atrial fibrillation, 19.4% were discharged on warfarin. The risk of bleeding (52.8%) and patient refusal (31.9%) were the main reasons for not prescribing anticoagulation. Larger/teaching hospitals were more likely to prescribe warfarin. Older patients, heavy drinkers, patients with higher National Institutes of Health Stroke Scale score on admission were less likely to be given warfarin, whereas patients with history of heart failure and an international normalized ratio between 2.0 and 3.0 during hospitalization were significantly associated with warfarin use at discharge.
  
  
  CONCLUSIONS
  The rate of warfarin use remains low among patients with ischemic stroke and known nonvalvular atrial fibrillation in China. Hospital size and academic status together with patient age, heart failure, heavy alcohol drinking, international normalized ratio in hospital, and stroke severity on admission were each independently associated with the use of warfarin at discharge. There is much room for improvement for secondary stroke prevention in nonvalvular atrial fibrillation patients in China.
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Xiaomeng
authors.initials: X
authors.lastname: Yang
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Zixiao
authors.initials: Z
authors.lastname: Li
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Xingquan
authors.initials: X
authors.lastname: Zhao
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Chunjuan
authors.initials: C
authors.lastname: Wang
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Liping
authors.initials: L
authors.lastname: Liu
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Chunxue
authors.initials: C
authors.lastname: Wang
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Yuesong
authors.initials: Y
authors.lastname: Pan
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Hao
authors.initials: H
authors.lastname: Li
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: David
authors.initials: D
authors.lastname: Wang
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.).
authors.forename: Robert G
authors.initials: RG
authors.lastname: Hart
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.). yongjunwang1962@gmail.com yilong528@gmail.com.
authors.forename: Yilong
authors.initials: Y
authors.lastname: Wang
authors.affiliation: From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Cerebrovascular Disease, China National Clinical Research Center for Neurological Diseases, Beijing, China (Z.L., X.Z., L.L., Chunxue Wang, H.L., Y.W., Y.W.); Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (Chunjuan Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China (Y.P.); Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St Francis Healthcare System, University of Illinois College of Medicine, Peoria (D.W.); and Department of Medicine, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (R.G.H.). yongjunwang1962@gmail.com yilong528@gmail.com.
authors.forename: Yongjun
authors.initials: Y
authors.lastname: Wang
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000428:Alcohol Drinking / Q000453:epidemiology; D000437:Alcoholism / Q000453:epidemiology; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D002681:China / Q000453:epidemiology; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006276:Health Facility Size / Q000706:statistics & numerical data; D006470:Hemorrhage; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D019934:International Normalized Ratio; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012042:Registries; D012306:Risk; D012307:Risk Factors; D055502:Secondary Prevention; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D016312:Treatment Refusal / Q000706:statistics & numerical data; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: China; atrial fibrillation; secondary prevention; stroke; warfarin