Abstract
Racial and ethnic disparities in health care are well documented, although often underappreciated.
In the setting of atrial fibrillation, stroke risk and severity may be higher in underrepresented
ethnic populations. Additionally, the risk of bleeding is not uniform, and pharmacogenetics
play an important role in anticoagulant therapy. In this narrative review, we discuss
the complex issues surrounding stroke prevention in underrepresented ethnic groups
with atrial fibrillation.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study.Heart. 2001; 86: 516-521
- Epidemiology of atrial fibrillation.Card Electrophysiol Clin. 2021; 13: 1-23
- Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.Stroke. 1991; 22: 983-988
- Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.Ann Intern Med. 2007; 146: 857-867
- Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.Lancet. 2014; 383: 955-962
- Trends of global burden of atrial fibrillation/flutter from Global Burden of Disease Study 2017.Heart. 2021; 107: 881-887
- Association of atrial fibrillation with mortality and disability after ischemic stroke.Neurology. 2013; 81: 825-832
- Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project.Stroke. 2002; 33: 238-242
- Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.Heart Rhythm. 2018; 15: 1337-1345
- Incidence of atrial fibrillation in whites and African-Americans: the Atherosclerosis Risk in Communities (ARIC) study.Am Heart J. 2009; 158: 111-117
- Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century.Int J Cardiol. 2013; 167: 1807-1824
- Anticoagulation control in different ethnic groups receiving vitamin K antagonist for stroke prevention in atrial fibrillation.Front Cardiovasc Med. 2021; 8736143
- Ethnicity in relation to atrial fibrillation and stroke (the West Birmingham Stroke Project).Am J Cardiol. 2003; 92: 1476-1479
- Differential impact of risk factors in blacks and whites in the development of atrial fibrillation: the reasons for geographic and racial differences in stroke (REGARDS) study.J Racial Ethn Health Disparities. 2017; 4: 718-724
- Ethnicity and stroke risk in patients with atrial fibrillation.Heart. 2013; 99: 1087-1092
- Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.Am Heart J. 2016; 174: 29-36
- Racial differences in atrial fibrillation epidemiology, management, and outcomes.Curr Treat Options Cardiovasc Med. 2019; 21: 85
- Epidemiology of atrial fibrillation: the Australian and Asia-Pacific perspective.Heart Lung Circ. 2017; 26: 870-879
- Racial differences in atrial fibrillation prevalence and left atrial size.Am J Med. 2010; 123: 375.e1-375.e7
- Genetics of atrial fibrillation: state of the art in 2017.Heart Lung Circ. 2017; 26: 894-901
- European ancestry as a risk factor for atrial fibrillation in African Americans.Circulation. 2010; 122: 2009-2015
- Identification, risk assessment, and management of patients with atrial fibrillation in a large primary care cohort.Int J Cardiol. 2018; 254: 119-124
- Racial/ethnic differences in ischemic stroke rates and the efficacy of warfarin among patients with atrial fibrillation.Stroke. 2008; 39: 2736-2743
- Disparities in stroke incidence contributing to disparities in stroke mortality.Ann Neurol. 2011; 69: 619-627
- Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation.Stroke. 2006; 37: 1070-1074
- Effect of race on outcomes (stroke and death) in patients >65 years with atrial fibrillation.Am J Cardiol. 2015; 116: 230-235
- Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study.Circulation. 2007; 116: 2157-2164
- Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites.Stroke. 2010; 41: 2132-2136
- Risk of stroke and intracranial hemorrhage in 9727 Chinese with atrial fibrillation in Hong Kong.Heart Rhythm. 2014; 11: 1401-1408
- Incident strokes among American Indian individuals with atrial fibrillation.J Am Heart Assoc. 2021; 10e019581
- Disparities and temporal trends in the use of anticoagulation in patients with ischemic stroke and atrial fibrillation.Stroke. 2019; 50: 1452-1459
- Racial variation in initial stroke severity.Stroke. 2000; 31: 563-567
- Comparison of clinical care and in-hospital outcomes of Asian American and White Patients with acute ischemic stroke.JAMA Neurol. 2019; 76: 430-439
- Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach.Chest. 2010; 137: 263-272
- Refining stroke prediction in atrial fibrillation patients by addition of African-American ethnicity to CHA2DS2-VASc score.J Am Coll Cardiol. 2016; 68: 461-470
- CHA2DS2-VASc score and stroke prediction in atrial fibrillation in whites, blacks, and Hispanics.Stroke. 2019; 50: 28-33
- Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review.Circ Cardiovasc Qual Outcomes. 2008; 1: 84-91
- Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries: the RE-LY Atrial Fibrillation Registry.Circulation. 2014; 129: 1568-1576
- Race/ethnicity, quality of care, and outcomes in ischemic stroke.Circulation. 2010; 121: 1492-1501
- Racial differences in the utilization of oral anticoagulant therapy in heart failure: a study of elderly hospitalized patients.J Gen Intern Med. 2000; 15: 134-137
- Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.Stroke. 2010; 41: 581-587
- Racial disparities in receipt of secondary stroke prevention agents among US nursing home residents.Stroke. 2003; 34: 2693-2697
- Burden of disease from atrial fibrillation in adults from seven countries in Latin America.Int J Gen Med. 2014; 7: 441-448
- Racial disparity in the prescription of anticoagulants and risk of stroke and bleeding in atrial fibrillation patients.J Stroke Cerebrovasc Dis. 2020; 29104718
- Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation.Thromb Res. 2020; 192: 12-20
- Managing stroke risk in patients with atrial fibrillation: a cross-sectional analysis of socio-demographic inequalities in a London borough.J Public Health (Oxf). 2022; 44: e241-e248
- Racial differences in quality of anticoagulation therapy for atrial fibrillation (from the TREAT-AF study).Am J Cardiol. 2016; 117: 61-68
- Cytochrome P450 2C9 polymorphisms: a comprehensive review of the in-vitro and human data.Pharmacogenetics. 2002; 12: 251-263
- Genetic variants associated with warfarin dose in African-American individuals: a genome-wide association study.Lancet. 2013; 382: 790-796
- Pharmacogenetics of warfarin in a diverse patient population.J Cardiovasc Pharmacol Ther. 2019; 24: 521-533
- The influence of ethnicity on warfarin dosage requirement.Ann Pharmacother. 2005; 39: 1008-1012
- The lowest effective intensity of prophylactic anticoagulation for patients with atrial fibrillation.Cerebrovasc Dis. 2005; 20: 114-119
- Warfarin anticoagulation intensity in Japanese nonvalvular atrial fibrillation patients: a J-RHYTHM Registry analysis.J Cardiol. 2015; 65: 175-177
- Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation.Stroke. 2013; 44: 1891-1896
- Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation.J Am Coll Cardiol. 2007; 50: 309-315
- Ethnic and racial variation in intracerebral hemorrhage risk factors and risk factor burden.JAMA Netw Open. 2021; 4e2121921
- 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the Europe.Eur Heart J. 2021; 42: 373-498
- Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation.J Am Coll Cardiol. 2017; 69: 2475-2484
- A systematic review and Bayesian network meta-analysis of risk of intracranial hemorrhage with direct oral anticoagulants.J Thromb Haemost. 2018; 16: 1296-1306
- Racial and ethnic differences in response to anticoagulation: a review of the literature.J Pharm Pract. 2021; 34: 685-693
- Rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation.Circ J. 2012; 76: 2104-2111
- Non-prescription of anticoagulants in patients discharged with stroke and atrial fibrillation.Br J Cardiol. 2019; 26: 23-26
National Institute for Health and Clinical Excellence (NICE). Atrial Fibrillation: Diagnosis and Management (NICE Guideline NG196). Available at: https://www.nice.org.uk/guidance/ng196/. Accessed April 18, 2022.
- Antithrombotic therapy use in patients with atrial fibrillation before the era of non-vitamin K antagonist oral anticoagulants: the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phase I cohort.Europace. 2016; 18: 1308-1318
- Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.Lancet. 2009; 374: 534-542
- Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial.JAMA. 2014; 312: 1988-1998
- Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.J Am Coll Cardiol. 2014; 64: 1-12
- Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation.Heart Rhythm. 2021; 18: 987-994
- Racial disparities in the utilization and outcomes of structural heart disease interventions in the United States.J Am Heart Assoc. 2019; 8e012125
- Racial disparities in in-hospital adverse events among patients with atrial fibrillation implanted with a Watchman left atrial appendage occlusion device: a US national perspective.Circ Arrhythm Electrophysiol. 2021; 14e009691
- Racial, ethnic and socioeconomic disparities in patients undergoing left atrial appendage closure.Heart. 2021; 107: 1946-1955
- Left atrial, pulmonary vein, and left atrial appendage anatomy in Indigenous individuals: Implications for atrial fibrillation.Int J Cardiol Heart Vasc. 2021; 34100775
- Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.Heart Rhythm. 2015; 12: 1406-1412
- Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM trial.J Natl Med Assoc. 2006 Mar; 98: 330-339
- 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study.Lancet. 2015; 386: 154-162
- Patients’ understanding of anticoagulant therapy in a multiethnic population.J R Soc Med. 2003; 96: 175-179
- Disparities in knowledge of heart attack and stroke symptoms among adult men: an analysis of behavioral risk factor surveillance survey data.J Natl Med Assoc. 2008; 100: 1116-1124
- Stroke risk factor status and use of stroke prevention medications among Hispanic/Latino adults in HCHS/SOL.Stroke. 2021; 52: 1339-1346
- Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial.PLoS One. 2013; 8: e74037
- Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TT2R2 score-guided strategy in anticoagulant-naïve Thai patients with atrial fibrillation (TREATS-AF): a study protocol.BMJ Open. 2021; 11e051987
- Addressing disparities in stroke prevention for atrial fibrillation.Am J Med Qual. 2016; 31: 337-348
- The ABC pathway: an integrated approach to improve AF management.Nat Rev Cardiol. 2017; 14: 627-628
- 2021 Focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: executive summary.Thromb Haemost. 2022; 122: 20-47
- Comprehensive management with the ABC (Atrial fibrillation Better Care) pathway in clinically complex patients with atrial fibrillation: a post hoc ancillary analysis from the AFFIRM trial.J Am Heart Assoc. 2020; 9e014932
- Integrated care management of patients with atrial fibrillation and risk of cardiovascular events: the ABC (Atrial fibrillation Better Care) pathway in the ATHERO-AF study cohort.Mayo Clin Proc. 2019; 94: 1261-1267
- Improved population-based clinical outcomes of patients with atrial fibrillation by compliance with the simple ABC (Atrial fibrillation Better Care) pathway for integrated care management: a nationwide cohort study.Thromb Haemost. 2019; 119: 1695-1703
- Adherence to the ‘Atrial fibrillation Better Care’ pathway in patients with atrial fibrillation: impact on clinical outcomes—a systematic review and meta-analysis of 285,000 patients.Thromb Haemost. 2022; 122: 406-414
- Effects of the Atrial fibrillation Better Care pathway on outcomes among clinically complex Chinese patients with atrial fibrillation with multimorbidity and polypharmacy: a report from the ChiOTEAF Registry.J Am Heart Assoc. 2022; 11e024319
- Atrial fibrillation Better Care pathway adherent care improves outcomes in Chinese patients with atrial fibrillation.JACC: Asia. 2022; 2: 422-429
- Integrated care of atrial fibrillation using the ABC (Atrial fibrillation Better Care) pathway improves clinical outcomes in Chinese population: an analysis from the Chinese Atrial Fibrillation Registry.Front Cardiovasc Med. 2021; 8762245
- Application of the simple Atrial fibrillation Better Care pathway for integrated care management in frail patients with atrial fibrillation: a nationwide cohort study.J Arrhythm. 2020; 36: 668-677
- Relation of the ‘Atrial fibrillation Better Care (ABC) Pathway’ to the quality of anticoagulation in atrial fibrillation patients taking vitamin K antagonists.J Pers Med. 2022; 12: 487
- Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry.Eur J Clin Invest. 2021; 51: e13385
- Mobile health technology to improve care for patients with atrial fibrillation.J Am Coll Cardiol. 2020; 75: 1523-1534
- Mobile health technology-supported atrial fibrillation screening and integrated care: a report from the mAFA-II trial Long-term Extension Cohort.Eur J Intern Med. 2020; 82: 105-111
Article info
Publication history
Published online: December 07, 2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding: No funding was received in relation to this work.
Conflicts of Interest: PC: None. KT: speaker for Abbott and Medtronic and consulting for Sanofi. GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo (no fees are received personally). DG: Institutional research grants from Biosense Webster, Boston Scientific and Medtronic, and speaker fees from Boston Scientific. AA: Honoraria and consulting for Abbott, Medtronic, Boston Scientific, Sanofi, Philips, BioSig, Toray, Biosense Webster, Haemonetics, SoundCath (no fees are received personally).
Authorship: No new data were generated during the production of this work. All authors were involved in conception, drafting and critical review of the manuscript.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
