Advertisement

Racial and Ethnic Disparities in Stroke Prevention for Atrial Fibrillation

Published:December 07, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.11.009

      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 access
      One-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 Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Stewart S
        • Hart CL
        • Hole DJ
        • McMurray JJ
        Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study.
        Heart. 2001; 86: 516-521
        • Zhang J
        • Johnsen SP
        • Guo Y
        • Lip GYH
        Epidemiology of atrial fibrillation.
        Card Electrophysiol Clin. 2021; 13: 1-23
        • Wolf PA
        • Abbott RD
        • Kannel WB
        Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.
        Stroke. 1991; 22: 983-988
        • Hart RG
        • Pearce LA
        • Aguilar MI
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Ruff CT
        • Giugliano RP
        • Braunwald E
        • et al.
        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
        • Wang L
        • Ze F
        • Li J
        • et al.
        Trends of global burden of atrial fibrillation/flutter from Global Burden of Disease Study 2017.
        Heart. 2021; 107: 881-887
        • McGrath ER
        • Kapral MK
        • Fang J
        • et al.
        Association of atrial fibrillation with mortality and disability after ischemic stroke.
        Neurology. 2013; 81: 825-832
        • Lip GYH
        • Kamath S
        • Jafri M
        • Mohammed A
        • Bareford D
        Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project.
        Stroke. 2002; 33: 238-242
        • Ugowe FE
        • Jackson 2nd, LR
        • Thomas KL
        Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.
        Heart Rhythm. 2018; 15: 1337-1345
        • Alonso A
        • Agarwal SK
        • Soliman EZ
        • et al.
        Incidence of atrial fibrillation in whites and African-Americans: the Atherosclerosis Risk in Communities (ARIC) study.
        Am Heart J. 2009; 158: 111-117
        • Ball J
        • Carrington MJ
        • McMurray JJV
        • Stewart S
        Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century.
        Int J Cardiol. 2013; 167: 1807-1824
        • Zawawi NA
        • Abdul Halim Zaki I
        • Ming LC
        • Goh HP
        • Zulkifly HH
        Anticoagulation control in different ethnic groups receiving vitamin K antagonist for stroke prevention in atrial fibrillation.
        Front Cardiovasc Med. 2021; 8736143
        • Conway DSG
        • Lip GYH
        Ethnicity in relation to atrial fibrillation and stroke (the West Birmingham Stroke Project).
        Am J Cardiol. 2003; 92: 1476-1479
        • O'Neal WT
        • Judd SE
        • Limdi NA
        • et al.
        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
        • Mathur R
        • Pollara E
        • Hull S
        • Schofield P
        • Ashworth M
        • Robson J
        Ethnicity and stroke risk in patients with atrial fibrillation.
        Heart. 2013; 99: 1087-1092
        • Golwala H
        • Jackson 2nd, LR
        • Simon DN
        • et al.
        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
        • Nanda A
        • Kabra R
        Racial differences in atrial fibrillation epidemiology, management, and outcomes.
        Curr Treat Options Cardiovasc Med. 2019; 21: 85
        • Wong CX
        • Brown A
        • Tse HF
        • et al.
        Epidemiology of atrial fibrillation: the Australian and Asia-Pacific perspective.
        Heart Lung Circ. 2017; 26: 870-879
        • Marcus GM
        • Olgin JE
        • Whooley M
        • et al.
        Racial differences in atrial fibrillation prevalence and left atrial size.
        Am J Med. 2010; 123: 375.e1-375.e7
        • Fatkin D
        • Santiago CF
        • Huttner IG
        • Lubitz SA
        • Ellinor PT
        Genetics of atrial fibrillation: state of the art in 2017.
        Heart Lung Circ. 2017; 26: 894-901
        • Marcus GM
        • Alonso A
        • Peralta CA
        • et al.
        European ancestry as a risk factor for atrial fibrillation in African Americans.
        Circulation. 2010; 122: 2009-2015
        • Poppe KK
        • Doughty RN
        • Harwood M
        • et al.
        Identification, risk assessment, and management of patients with atrial fibrillation in a large primary care cohort.
        Int J Cardiol. 2018; 254: 119-124
        • Shen AYJ
        • Yao JF
        • Brar SS
        • Jorgensen MB
        • Wang X
        • Chen W
        Racial/ethnic differences in ischemic stroke rates and the efficacy of warfarin among patients with atrial fibrillation.
        Stroke. 2008; 39: 2736-2743
        • Howard VJ
        • Kleindorfer DO
        • Judd SE
        • et al.
        Disparities in stroke incidence contributing to disparities in stroke mortality.
        Ann Neurol. 2011; 69: 619-627
        • Birman-Deych E
        • Radford MJ
        • Nilasena DS
        • Gage BF
        Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation.
        Stroke. 2006; 37: 1070-1074
        • Kabra R
        • Cram P
        • Girotra S
        • Vaughan Sarrazin M
        Effect of race on outcomes (stroke and death) in patients >65 years with atrial fibrillation.
        Am J Cardiol. 2015; 116: 230-235
        • Markus HS
        • Khan U
        • Birns J
        • et al.
        Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study.
        Circulation. 2007; 116: 2157-2164
        • Simpson JR
        • Zahuranec DB
        • Lisabeth LD
        • et al.
        Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites.
        Stroke. 2010; 41: 2132-2136
        • Siu CW
        • Lip GYH
        • Lam KF
        • Tse HF
        Risk of stroke and intracranial hemorrhage in 9727 Chinese with atrial fibrillation in Hong Kong.
        Heart Rhythm. 2014; 11: 1401-1408
        • Sanchez JM
        • Jolly SE
        • Dewland TA
        • et al.
        Incident strokes among American Indian individuals with atrial fibrillation.
        J Am Heart Assoc. 2021; 10e019581
        • Sur NB
        • Wang K
        • di Tullio MR
        • et al.
        Disparities and temporal trends in the use of anticoagulation in patients with ischemic stroke and atrial fibrillation.
        Stroke. 2019; 50: 1452-1459
        • Jones MR
        • Horner RD
        • Edwards LJ
        • et al.
        Racial variation in initial stroke severity.
        Stroke. 2000; 31: 563-567
        • Song S
        • Liang L
        • Fonarow GC
        • et al.
        Comparison of clinical care and in-hospital outcomes of Asian American and White Patients with acute ischemic stroke.
        JAMA Neurol. 2019; 76: 430-439
        • Lip GYH
        • Nieuwlaat R
        • Pisters R
        • Lane DA
        • Crijns HJGM
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach.
        Chest. 2010; 137: 263-272
        • Kabra R
        • Girotra S
        • Vaughan Sarrazin M
        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
        • Chen LY
        • Norby FL
        • Chamberlain AM
        • et al.
        CHA2DS2-VASc score and stroke prediction in atrial fibrillation in whites, blacks, and Hispanics.
        Stroke. 2019; 50: 28-33
        • Wan Y
        • Heneghan C
        • Perera R
        • et al.
        Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review.
        Circ Cardiovasc Qual Outcomes. 2008; 1: 84-91
        • Oldgren J
        • Healey JS
        • Ezekowitz M
        • et al.
        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
        • Schwamm LH
        • Reeves MJ
        • Pan W
        • et al.
        Race/ethnicity, quality of care, and outcomes in ischemic stroke.
        Circulation. 2010; 121: 1492-1501
        • Ibrahim SA
        • Kwoh CK
        • Harper DL
        • Baker DW
        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
        • Meschia JF
        • Merrill P
        • Soliman EZ
        • et al.
        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
        • Christian JB
        • Lapane KL
        • Toppa RS
        Racial disparities in receipt of secondary stroke prevention agents among US nursing home residents.
        Stroke. 2003; 34: 2693-2697
        • Cubillos L
        • Haddad A
        • Kuznik A
        • Mould-Quevedo J
        Burden of disease from atrial fibrillation in adults from seven countries in Latin America.
        Int J Gen Med. 2014; 7: 441-448
        • Tedla YG
        • Schwartz SM
        • Silberman P
        • Greenland P
        • Passman RS
        Racial disparity in the prescription of anticoagulants and risk of stroke and bleeding in atrial fibrillation patients.
        J Stroke Cerebrovasc Dis. 2020; 29104718
        • Zulkifly H
        • Cheli P
        • Lutchman I
        • Bai Y
        • Lip GYH
        • Lane DA
        Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation.
        Thromb Res. 2020; 192: 12-20
        • Wou C
        • Crompton J
        • Ashworth M
        • Williams H
        • Dodhia H
        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
        • Yong C
        • Azarbal F
        • Abnousi F
        • Heidenreich PA
        • Schmitt S
        • Fan J
        • et al.
        Racial differences in quality of anticoagulation therapy for atrial fibrillation (from the TREAT-AF study).
        Am J Cardiol. 2016; 117: 61-68
        • Lee CR
        • Goldstein JA
        • Pieper JA
        Cytochrome P450 2C9 polymorphisms: a comprehensive review of the in-vitro and human data.
        Pharmacogenetics. 2002; 12: 251-263
        • Perera MA
        • Cavallari LH
        • Limdi NA
        • et al.
        Genetic variants associated with warfarin dose in African-American individuals: a genome-wide association study.
        Lancet. 2013; 382: 790-796
        • Mak M
        • Lam C
        • Pineda SJ
        • et al.
        Pharmacogenetics of warfarin in a diverse patient population.
        J Cardiovasc Pharmacol Ther. 2019; 24: 521-533
        • Dang MTN
        • Hambleton J
        • Kayser SR
        The influence of ethnicity on warfarin dosage requirement.
        Ann Pharmacother. 2005; 39: 1008-1012
        • Cheung CM
        • Tsoi TH
        • Huang CY
        The lowest effective intensity of prophylactic anticoagulation for patients with atrial fibrillation.
        Cerebrovasc Dis. 2005; 20: 114-119
        • Yamashita T
        • Inoue H
        • Okumura K
        • Atarashi H
        • Origasa H
        • J-RHYTHM Registry Investigators
        Warfarin anticoagulation intensity in Japanese nonvalvular atrial fibrillation patients: a J-RHYTHM Registry analysis.
        J Cardiol. 2015; 65: 175-177
        • Hori M
        • Connolly SJ
        • Zhu J
        • et al.
        Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation.
        Stroke. 2013; 44: 1891-1896
        • Shen AYJ
        • Yao JF
        • Brar SS
        • Jorgensen MB
        • Chen W
        Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation.
        J Am Coll Cardiol. 2007; 50: 309-315
        • Kittner SJ
        • Sekar P
        • Comeau ME
        • et al.
        Ethnic and racial variation in intracerebral hemorrhage risk factors and risk factor burden.
        JAMA Netw Open. 2021; 4e2121921
        • Hindricks G
        • Potpara T
        • Dagres N
        • et al.
        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
        • Marzec LN
        • Wang J
        • Shah ND
        • et al.
        Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation.
        J Am Coll Cardiol. 2017; 69: 2475-2484
        • Wolfe Z
        • Khan SU
        • Nasir F
        • Raghu Subramanian C
        • Lash B
        A systematic review and Bayesian network meta-analysis of risk of intracranial hemorrhage with direct oral anticoagulants.
        J Thromb Haemost. 2018; 16: 1296-1306
        • Gibson CM
        • Yuet WC
        Racial and ethnic differences in response to anticoagulation: a review of the literature.
        J Pharm Pract. 2021; 34: 685-693
        • Hori M
        • Matsumoto M
        • Tanahashi N
        • et al.
        Rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation.
        Circ J. 2012; 76: 2104-2111
        • Creaney C
        • Barkat K
        • Durey C
        • et al.
        Non-prescription of anticoagulants in patients discharged with stroke and atrial fibrillation.
        Br J Cardiol. 2019; 26: 23-26
      1. 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.

        • Huisman M
        • Ma CS
        • Diener HC
        • et al.
        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
        • Holmes DR
        • Reddy VY
        • Turi ZG
        • et al.
        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
        • Reddy VY
        • Sievert H
        • Halperin J
        • et al.
        Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial.
        JAMA. 2014; 312: 1988-1998
        • Holmes DR
        • Kar S
        • Price MJ
        • et al.
        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
        • Vincent L
        • Grant J
        • Ebner B
        • et al.
        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
        • Alkhouli M
        • Alqahtani F
        • Holmes DR
        • Berzingi C
        Racial disparities in the utilization and outcomes of structural heart disease interventions in the United States.
        J Am Heart Assoc. 2019; 8e012125
        • Khan MZ
        • Munir MB
        • Darden D
        • et al.
        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
        • Sparrow R
        • Sanjoy S
        • Choi YH
        • et al.
        Racial, ethnic and socioeconomic disparities in patients undergoing left atrial appendage closure.
        Heart. 2021; 107: 1946-1955
        • Clarke NAR
        • Kangaharan N
        • Costello B
        • et al.
        Left atrial, pulmonary vein, and left atrial appendage anatomy in Indigenous individuals: Implications for atrial fibrillation.
        Int J Cardiol Heart Vasc. 2021; 34100775
        • Bhave PD
        • Lu X
        • Girotra S
        • Kamel H
        • Vaughan Sarrazin MS
        Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.
        Heart Rhythm. 2015; 12: 1406-1412
        • Bush D
        • Martin LW
        • Leman R
        • Chandler M
        • Haywood LJ
        • NHLBI AFFIRM Investigators
        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
        • Schnabel RB
        • Yin X
        • Gona P
        • et al.
        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
        • Nadar S
        • Begum N
        • Kaur B
        • Sandhu S
        • Lip GYH
        Patients’ understanding of anticoagulant therapy in a multiethnic population.
        J R Soc Med. 2003; 96: 175-179
        • Lutfiyya MN
        • Lipsky MS
        • Bales RW
        • Cha I
        • McGrath C
        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
        • Bai F
        • Chen J
        • Pandey D
        • et al.
        Stroke risk factor status and use of stroke prevention medications among Hispanic/Latino adults in HCHS/SOL.
        Stroke. 2021; 52: 1339-1346
        • Clarkesmith DE
        • Pattison HM
        • Lip GYH
        • Lane DA
        Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial.
        PLoS One. 2013; 8: e74037
        • Phrommintikul A
        • Nathisuwan S
        • Gunaparn S
        • et al.
        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
        • Karcher R
        • Berman AE
        • Gross H
        • et al.
        Addressing disparities in stroke prevention for atrial fibrillation.
        Am J Med Qual. 2016; 31: 337-348
        • Lip GYH
        The ABC pathway: an integrated approach to improve AF management.
        Nat Rev Cardiol. 2017; 14: 627-628
        • Chao TF
        • Joung B
        • Takahashi Y
        • et al.
        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
        • Proietti M
        • Romiti GF
        • Olshansky B
        • Lane DA
        • Lip GYH
        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
        • Pastori D
        • Pignatelli P
        • Menichelli D
        • Violi F
        • Lip GYH
        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
        • Yoon M
        • Yang PS
        • Jang E
        • et al.
        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
        • Romiti GF
        • Pastori D
        • Rivera-Caravaca JM
        • et al.
        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
        • Kotalczyk A
        • Guo Y
        • Stefil M
        • Wang Y
        • Lip GYH
        • ChiOTEAF Registry Investigators
        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
        • Guo Y
        • Imberti JF
        • Kotalczyk A
        • Wang Y
        • Lip GYH
        Atrial fibrillation Better Care pathway adherent care improves outcomes in Chinese patients with atrial fibrillation.
        JACC: Asia. 2022; 2: 422-429
        • Wang YF
        • Jiang C
        • He L
        • et al.
        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
        • Yang PS
        • Sung JH
        • Jang E
        • et al.
        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
        • Roldán V
        • Martínez-Montesinos L
        • López-Gálvez R
        • et al.
        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
        • Domek M
        • Gumprecht J
        • Li YG
        • et al.
        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
        • Guo Y
        • Lane DA
        • Wang L
        • et al.
        Mobile health technology to improve care for patients with atrial fibrillation.
        J Am Coll Cardiol. 2020; 75: 1523-1534
        • Guo Y
        • Guo J
        • Shi X
        • et al.
        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