Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Original Article

Volume 12, Number 4, August 2021, pages 225-230

Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study

**Table 1.** Patient Characteristics of Anticoagulation Interruption Versus No Interruption Groups
Variables	Anticoagulant interruption 48 h+ (N = 79)	No anticoagulation interruption (N = 2,198)	P-value
SD: standard deviation; CVA: cerebrovascular accident; CHF: congestive heart failure; HTN: hypertension; LOS: length of hospital stay.
Age (mean ± SD)	76.35 ± 9.45	72.76 ± 11.14	0.001
Male, n (%)	32 (40.51)	1,091 (49.64)	0.14
CHA₂DS₂VASc (mean ± SD)	3.78 ± 1.23	3.42 ± 1.33	0.01
Ischemic CVA, n (%)	1 (1.27)	5 (0.23)	0.19
CHF, n (%)	43 (54.43)	666 (30.30)	< 0.001
HTN, n (%)	31 (39.24)	1,247 (56.73)	0.002
Age ≥ 75 years, n (%)	49 (62.03)	1,039 (47.27)	0.011
Age 65 - 74 years, n (%)	21 (26.58)	731 (33.26)	0.23
Diabetes, n (%)	20 (25.32)	629 (28.62)	0.61
Vascular disease, n (%)	37 (46.84)	972 (44.22)	0.65
Bleeding, n (%)	3 (3.80)	20 (0.91)	0.04
Mortality, n (%)	0 (0)	5 (0.23)	1.00
Readmission within 90 days, n (%)	38 (48.10)	799 (36.35)	0.04
Average LOS (mean ± SD)	7.54 ± 4.58	2.55 ± 2.19	< 0.0001

Table 1. Patient Characteristics of Anticoagulation Interruption Versus No Interruption Groups

Variables

Anticoagulant interruption 48 h+ (N = 79)

No anticoagulation interruption (N = 2,198)

P-value

SD: standard deviation; CVA: cerebrovascular accident; CHF: congestive heart failure; HTN: hypertension; LOS: length of hospital stay.

Age (mean ± SD)

76.35 ± 9.45

72.76 ± 11.14

0.001

Male, n (%)

32 (40.51)

1,091 (49.64)

0.14

CHA₂DS₂VASc (mean ± SD)

3.78 ± 1.23

3.42 ± 1.33

0.01

Ischemic CVA, n (%)

1 (1.27)

5 (0.23)

0.19

CHF, n (%)

43 (54.43)

666 (30.30)

< 0.001

HTN, n (%)

31 (39.24)

1,247 (56.73)

0.002

Age ≥ 75 years, n (%)

49 (62.03)

1,039 (47.27)

0.011

Age 65 - 74 years, n (%)

21 (26.58)

731 (33.26)

0.23

Diabetes, n (%)

20 (25.32)

629 (28.62)

0.61

Vascular disease, n (%)

37 (46.84)

972 (44.22)

0.65

Bleeding, n (%)

3 (3.80)

20 (0.91)

0.04

Mortality, n (%)

0 (0)

5 (0.23)

1.00

Readmission within 90 days, n (%)

38 (48.10)

799 (36.35)

0.04

Average LOS (mean ± SD)

7.54 ± 4.58

2.55 ± 2.19

< 0.0001

**Table 2.** Association of Selected Factors With Acute In-Hospital Ischemic Stroke in Hospitalized Patients With a History of AF
Variables	Ischemic CVA	No ischemic CVA	P-value
AF: atrial fibrillation; SD: standard deviation; CVA: cerebrovascular accident; CHF: congestive heart failure; HTN: hypertension; LOS: length of hospital stay.
Age (mean ± SD)	77.00 ± 6.57 (N = 6)	72.87 ± 11.12 (N = 2,271)	0.1853
Male, n (%)	2 (33.33)	1,121 (49.36)	0.6873
Female, n (%)	4 (66.66)	1,150 (50.64)	0.6873
CHA₂DS₂VASc (mean ± SD)	6.00 ± 0.894	3.4280 ± 1.32	0.0009
CHF, n (%)	1 (16.67)	708 (31.18)	0.6725
HTN, n (%)	5 (83.33)	1,273 (56.05)	0.2392
Age ≥ 75 years, n (%)	4 (66.67)	1,084 (47.73)	0.4342
Age 65 - 74 years, n (%)	2 (33.33)	750 (33.03)	1.0000
Diabetes, n (%)	2 (33.33)	647 (28.49)	0.6803
Vascular disease, n (%)	2 (33.33)	1,007 (44.34)	0.6991
Anticoagulation interrupted, n (%)	1 (16.67)	78 (3.43)	0.1911
No anticoagulation interruption, n (%)	5 (83.33)	2,193 (96.57)	0.1911
Bleeding, n (%)	0 (0)	23 (1.01)	1.000
Mortality, n (%)	0 (0)	5 (0.22)	1.000
Readmission within 90 days, n (%)	3 (50)	834 (36.72)	0.6754
Average LOS (mean ± SD)	6.50 ± 10.13	2.71 ± 2.44	0.4021

Table 2. Association of Selected Factors With Acute In-Hospital Ischemic Stroke in Hospitalized Patients With a History of AF

Variables

Ischemic CVA

No ischemic CVA

P-value

AF: atrial fibrillation; SD: standard deviation; CVA: cerebrovascular accident; CHF: congestive heart failure; HTN: hypertension; LOS: length of hospital stay.

Age (mean ± SD)

77.00 ± 6.57 (N = 6)

72.87 ± 11.12 (N = 2,271)

0.1853

Male, n (%)

2 (33.33)

1,121 (49.36)

0.6873

Female, n (%)

4 (66.66)

1,150 (50.64)

0.6873

CHA₂DS₂VASc (mean ± SD)

6.00 ± 0.894

3.4280 ± 1.32

0.0009

CHF, n (%)

1 (16.67)

708 (31.18)

0.6725

HTN, n (%)

5 (83.33)

1,273 (56.05)

0.2392

Age ≥ 75 years, n (%)

4 (66.67)

1,084 (47.73)

0.4342

Age 65 - 74 years, n (%)

2 (33.33)

750 (33.03)

1.0000

Diabetes, n (%)

2 (33.33)

647 (28.49)

0.6803

Vascular disease, n (%)

2 (33.33)

1,007 (44.34)

0.6991

Anticoagulation interrupted, n (%)

1 (16.67)

78 (3.43)

0.1911

No anticoagulation interruption, n (%)

5 (83.33)

2,193 (96.57)

0.1911

Bleeding, n (%)

0 (0)

23 (1.01)

1.000

Mortality, n (%)

0 (0)

5 (0.22)

1.000

Readmission within 90 days, n (%)

3 (50)

834 (36.72)

0.6754

Average LOS (mean ± SD)

6.50 ± 10.13

2.71 ± 2.44

0.4021

**Table 3.** CHA₂DS₂VASc Significantly Associated With the Outcome Variable of In-Hospital CVA
Effect	Odds ratio	95% Confidence interval
Patients with higher CHA₂DS₂VASc scores are more likely than those with lower CHA₂DS₂VASc scores to have an in-hospital CVA. CHA₂DS₂VASc: congestive heart failure/left ventricular dysfunction, hypertension, age > 75 (two points), diabetes mellitus, history of stroke/TIA or thromboembolism (two points), vascular disease (prior myocardial infarction, peripheral artery disease, aortic plaque), age 65 - 74, sex category. CVA: cerebrovascular accident; TIA: transient ischemic attack.
Any interruption 48+ h (1: presence vs. 0: no presence)	4.21	0.39	44.89
CHA₂DS₂VASc	7.20	2.92	17.75

Table 3. CHA₂DS₂VASc Significantly Associated With the Outcome Variable of In-Hospital CVA

Effect

Odds ratio

95% Confidence interval

Patients with higher CHA₂DS₂VASc scores are more likely than those with lower CHA₂DS₂VASc scores to have an in-hospital CVA. CHA₂DS₂VASc: congestive heart failure/left ventricular dysfunction, hypertension, age > 75 (two points), diabetes mellitus, history of stroke/TIA or thromboembolism (two points), vascular disease (prior myocardial infarction, peripheral artery disease, aortic plaque), age 65 - 74, sex category. CVA: cerebrovascular accident; TIA: transient ischemic attack.

Any interruption 48+ h (1: presence vs. 0: no presence)

4.21

0.39

44.89

CHA₂DS₂VASc

7.20

2.92

17.75

**Table 4.** Incidence of Acute Ischemic CVA in Relation to CHA₂DS₂VASc Risk Categories
CHA₂DS₂VASc risk groups	Acute ischemic CVA in patients with AC interruption	Acute ischemic CVA in patients without AC interruption	P-value
There is not a significant difference in the number of people that had a stroke between interruption and non-interruption groups, within each CHA₂DS₂VASc risk category. Majority of the patients who suffered stroke were in the intermediate and high-risk categories. CVA: cerebrovascular accident; AC: anticoagulation.
Low risk (score of 0 - 4) (N = 1,818)	0/60 (0%)	0/1,758 (0%)	1.000
Intermediate risk (score of 5 - 6) (N = 446)	0/18 (0%)	4/428 (0.94%)	1.000
High risk (score ≥ 7) (N = 13)	1/1 (100%)	1/12 (8.33%)	0.1538

Table 4. Incidence of Acute Ischemic CVA in Relation to CHA₂DS₂VASc Risk Categories

CHA₂DS₂VASc risk groups

Acute ischemic CVA in patients with AC interruption

Acute ischemic CVA in patients without AC interruption

P-value

There is not a significant difference in the number of people that had a stroke between interruption and non-interruption groups, within each CHA₂DS₂VASc risk category. Majority of the patients who suffered stroke were in the intermediate and high-risk categories. CVA: cerebrovascular accident; AC: anticoagulation.

Low risk (score of 0 - 4) (N = 1,818)

0/60 (0%)

0/1,758 (0%)

1.000

Intermediate risk (score of 5 - 6) (N = 446)

0/18 (0%)

4/428 (0.94%)

1.000

High risk (score ≥ 7) (N = 13)

1/1 (100%)

1/12 (8.33%)

0.1538

**Table 5.** Details of the Six Patients Who Developed a Stroke in the Hospital
Patient	Primary final diagnosis	Secondary diagnoses	INR on admission	Anticoagulant prior to admission	Anticoagulation interruption > 48 h
AF: atrial fibrillation; AFL: atrial flutter; DM: diabetes mellitus; HTN: hypertension; HLD: hyperlipidemia; OSA: obstructive sleep apnea; COPD: chronic obstructive pulmonary disease; HFpEF: heart failure with preserved ejection fraction; PVD: peripheral vascular disease; CKD: chronic kidney disease; CAD: coronary artery disease; AMS: altered mental status; CAP: community-acquired pneumonia; NHL: non-Hodgkin’s lymphoma.
1	Paroxysmal AF	Type 2 DM, HTN, HLD, obesity	0.96	Apixaban 5 mg twice daily	No
2	AFL	Type 2 DM, HTN, HLD, OSA, obesity	1.03	Warfarin 3 mg daily	No
3	Atherosclerotic heart disease	AF, HTN, HLD, dementia	4.47	Warfarin 4 mg daily	No
4	AFL	HTN, HLD, COPD, HFpEF, PVD, CKD, CAD, history of lung cancer	1.10	Rivaroxaban 10 mg daily	No
5	AF	AMS, HTN, HLD	0.97	Apixaban 2.5 mg twice daily	No
6	AFL	CAP, severe sepsis with septic shock, COPD, acute post-hemorrhagic anemia, AKI, HFpEF, NHL, obesity, hypothyroidism	1.47	None	Yes

Table 5. Details of the Six Patients Who Developed a Stroke in the Hospital

Patient

Primary final diagnosis

Secondary diagnoses

INR on admission

Anticoagulant prior to admission

Anticoagulation interruption > 48 h

AF: atrial fibrillation; AFL: atrial flutter; DM: diabetes mellitus; HTN: hypertension; HLD: hyperlipidemia; OSA: obstructive sleep apnea; COPD: chronic obstructive pulmonary disease; HFpEF: heart failure with preserved ejection fraction; PVD: peripheral vascular disease; CKD: chronic kidney disease; CAD: coronary artery disease; AMS: altered mental status; CAP: community-acquired pneumonia; NHL: non-Hodgkin’s lymphoma.

Paroxysmal AF

Type 2 DM, HTN, HLD, obesity

0.96

Apixaban 5 mg twice daily

AFL

Type 2 DM, HTN, HLD, OSA, obesity

1.03

Warfarin 3 mg daily

Atherosclerotic heart disease

AF, HTN, HLD, dementia

4.47

Warfarin 4 mg daily

AFL

HTN, HLD, COPD, HFpEF, PVD, CKD, CAD, history of lung cancer

1.10

Rivaroxaban 10 mg daily

AMS, HTN, HLD

0.97

Apixaban 2.5 mg twice daily

AFL

CAP, severe sepsis with septic shock, COPD, acute post-hemorrhagic anemia, AKI, HFpEF, NHL, obesity, hypothyroidism

1.47

None

Yes