Burden of Atrial Fibrillation in Patients with Spontaneous Intracerebral Hemorrhage in Florence District over the Years

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Atrial fibrillation (AF) is the most commonly found arrhythmia in clinical practice, and represents a public healthcare problem worldwide. Its incidence and prevalence increase steadily with age. Prevention of AF-related cardio embolism, and especially of embolic strokes, which represent about one third of all ischemic strokes, is one of the main goals of AF treatment. Oral anticoagulation, both with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), represents the treatment of choice for preventing cardio embolism. Therefore, in the last decades many efforts have been made to increase physician’s confidence in the appropriate management of AF. Due to high acute mortality and severe neurological disability, spontaneous intracerebral hemorrhage (ICH) represents the most devastating stroke subtype. The 30-day mortality rate approaches 40%, and seems to have remained unchanged over the last 30 years. In the acute phase, few specific treatments, such anti-hypertensive drugs and reversal therapy in coagulopathy-associated ICH, are available only for selected patients, and their benefits are questionable. Literature evidence about the real burden of AF in patients with spontaneous ICH is lacking. Therefore, the aim of our study was to provide answer to this issue.

We reviewed the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9th CM) database referred to patients discharged from the six Hospitals of Florence district (Careggi Hospital, Santa Maria Nuova Hospital, Santa Maria Annunziata Hospital, San Giovanni di Dio Hospital, Figline Valdarno Hospital and Borgo San Lorenzo Hospital), Tuscany, Italy in a 15-year period (2001-2015). Code 431 (spontaneous ICH) was searched as primary or secondary diagnosis, and then matched with code 427.31 (AF) in one of the other discharge diagnoses. The endpoints of this research were the number of cases of spontaneous ICH and AF, and the number of deaths occurred every year in patients with spontaneous ICH associated or not with AF. The burden of AF in patients with spontaneous ICH, and in-hospital mortality were reported as percentage of diagnoses.

Overall, 7452 patients were discharged with ICH as primary or secondary diagnosis. Of them, 3695 (49.5%) were females. 4363 patients (59.1%) were 75-years old and older, whereas 1678 (22.5%) were 65-75 years old, and 1411 (18.4%) under the age of 65 years. Six hundred and ninety-three patients (9.2%) had AF. The burden of AF increased with age (1.5% in patients under the age of 65 years, 6.4% in patients aged 65- 75 years, and 12.8% in those older than 75 years), and over the years (5.6% in 2001, 8.9% in 2008, and 11.4% in 2015) (Figure 1), irrespective of age. In-hospital mortality decreased over the years both in patients with and without AF (Figure 2). However, in patients with AF-related ICH, in-hospital mortality was significantly higher than in those without AF (29.4% vs 23.3%, p=0.04).