Editorial
Action Required to Maximize Protection against Ischemic Stroke among Patients with Atrial Fibrillation
2025 年 32 巻 3 号 p. 304-305
詳細
2025 年 32 巻 3 号 p. 304-305
See article vol. 32: 308-320
In this issue of the Journal of Atherosclerosis and Thrombosis, Toyoda et al. reported a secular trend in the severity/prognosis of ischemic stroke patients with atrial fibrillation from 2000 to 2020, using the nationwide stroke registry in Japan (the Japan Stroke Data Bank: JSDB)1). In this study, the initial stroke severity defined by the National Institutes of Health Stroke Scale (NIHSS) has become milder, and favorable functional outcomes defined by the modified Rankin scale (mRS) of 0-2 have increased over the 21-year period from 2000 to 2020 among ischemic stroke patients with atrial fibrillation. The recent decrease in the initial severity of acute ischemic stroke among patients with atrial fibrillation might be attributable in part to improvements in ischemic stroke prevention strategies for patients with atrial fibrillation, including increased use of oral anticoagulants, launch of direct oral anticoagulants (DOAC), and better control of blood pressure (BP). The recent increase in favorable functional outcomes after ischemic stroke complicated with atrial fibrillation might also be attributable to better stroke management, including the launch of alteplase for treatment of acute ischemic stroke in 2005, increased use of endovascular treatment, improvement of thrombectomy devices, etc., as well as improved prevention strategies and decreased initial severity, as described above. Despite improvements in stroke prevention strategies and management in recent years, the prognosis of ischemic stroke patients with atrial fibrillation is still much worse than that of patients without atrial fibrillation1). Further action is required to prevent ischemic stroke and improve functional outcomes after acute ischemia in patients with atrial fibrillation.
One possible intervention strategy to prevent ischemic stroke and improve functional outcomes after acute ischemic stroke would be to improve adherence to guideline-recommended treatments, including oral anticoagulants, for patients with atrial fibrillation. However, in the present analysis of the Japan Stroke Data Bank (JSDB), only 32% of patients with atrial fibrillation received oral anticoagulants before the onset of acute ischemic stroke1). Because the average age of ischemic stroke patients with atrial fibrillation in JSDB was 79 years old, with 69% of patients showing hypertension, 22% diabetes, and 31% a history of stroke, most patients seemed to have a CHADS2 score of ≥ 1 and are likely to be candidates for anticoagulant therapy. A population-based nationwide survey in China also found that only 6% of patients with atrial fibrillation received anticoagulant therapy2). Strategies to improve adherence to guideline-recommended treatments, including anticoagulant therapy, are urgently needed in East Asia as well as other regions of the world.
Low anticoagulation rates in patients with atrial fibrillation might be attributable to a lack of awareness, lack of hospital visits, clinical inertia, etc. Awareness of atrial fibrillation may be increased not only by performing electrocardiography during health checkups but also by the active use of wearable devices and/or portable electrocardiographs. To increase the rate of hospital visits, it would be useful to identify patients who are aware of atrial fibrillation but do not intend to visit hospitals, use medical checkups and medical claim data, and encourage them to visit hospitals by phone or in person. To overcome the clinical inertia of patients with atrial fibrillation who visit hospitals, it is important to provide team-based medical care and guidance through a multidisciplinary approach. It is also important to implement other evidence-based treatments. For example, a subgroup analysis of large-scale clinical trials suggested benefits of BP-lowering treatment among patients with atrial fibrillation3, 4), and definite evidence of benefits/harms of intensive BP-lowering in patients with atrial fibrillation will be provided by the ongoing CRAFT trial5).
In conclusion, a multifactorial, comprehensive approach to enhancing guideline-recommended treatments (i.e. oral anticoagulants, BP lowering, etc.), including the use of latest digital technologies to detect and monitor patients with atrial fibrillation and team-based approaches, is now required to provide maximum protection against the enormous burden of ischemic stroke among patients with atrial fibrillation.
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