Atrial Fibrillation, Stroke, and Acute Antithrombotic Therapy

Abstract

Background— Strokes in patients with atrial fibrillation (AF) are typically larger, are associated with higher early mortality, and occur in older patients versus strokes in patients with sinus rhythm. Until recently, the value of antithrombotic therapies for acute stroke management has been based on empiric evidence. Summary of Review— We present a critical review of 3 randomized clinical trials testing aspirin, heparin/heparinoid, or both involving 5029 patients with AF and acute stroke. Early recurrent ischemic stroke occurred in about 5% of patients during the 2 to 4 weeks after initial stroke. Data conflict about whether early use of heparin/heparinoid reduced early recurrent ischemic stroke but are consistent regarding its lack of overall benefit on long-term functional outcome. Modest benefits for reduction of early recurrent stroke and functional outcome were associated with aspirin use, based largely on subgroup analysis from a single, large, unblinded trial. Conclusions— No benefit of heparin has been demonstrated for acute stroke patients with AF; whether selected subgroups would respond differently remains to be proven. Aspirin followed by early initiation of warfarin for long-term secondary prevention is reasonable antithrombotic management.

Rapid Assessment and Treatment of Transient Ischemic Attacks and Minor Stroke in Canadian Emergency Departments

“…15 Because atrial fibrillation is a leading treatable risk factor for stroke and TIA, stroke/TIA patients presenting in sinus rhythm may need additional ECG monitoring if occult paroxysmal atrial fibrillation is suspected. 16 Patients with intracranial occlusions may be considered for thrombolysis or at least monitored for symptom progression.…”

Atrial fibrillation and stroke in the perspective of new oral anticoagulants

“…AF hastalarında inmenin sekonder profilaksisinde özellikle akut dönemde tedavi yönetimi zorlayıcı olabilir. İskemik inme geçiren AF hastalarının erken dönemde (ilk 2 haftada) rekürren inme geçirme riski %5 civarındadır [8]. Hemorajik transformasyon bütün iskemik inmelerin yaklaşık %15'inde gözlenen bir klinik tabloyken bu oran kardiyoembolik inmelerde %30'dur [1].…”

“…Erken dönemde antikoagüle edilen hastalarda semptomatik hemorajik transformasyon riski %1-25 arasında değişir [1]. Erken dönemde atriyal fibrilasyon ilişkili inmede heparin kullanımı, rekürrensin önlenmesi bakımından fayda sağlayabilirken, hemorajik transformasyon riskini arttırmaktadır; bu nedenle akut dönemde antikoagülasyon ancak seçilmiş durumlarda kullanılmalıdır [8].…”

Acute Ischemic Stroke Treatment in 2007

“…Individual trial reviews published in 2002 (ie, after the Cochrane report) concluded that most patients with acute ischemic stroke should not be treated with unfractionated heparin or other rapidly acting anticoagulants and that there was no overall benefit of treatment with heparin in patients with acute ischemic stroke and atrial fibrillation. 69,70 A 2002 guideline statement jointly developed by the American Stroke Association and the American Academy of Neurology was based on a systematic literature review. 71 Recommendations are given in Table 4 and were reiterated in a subsequent guideline statement from the American Stroke Association.…”