Not All Patients With Atrial Fibrillation–Associated Ischemic Stroke Can Be Started on Anticoagulant Therapy

Abstract

Background and Purpose-Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke.Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. Methods-All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. Results-Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (PϽ0.001) and 23 (56%) were discharged to institutional care (PϽ0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). Conclusions-In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.

Clinical outcomes three years after PLAATO implantation

“…Furthermore, in a study by Hylek et al, 49% of elderly AF patients (with 2 stroke risk factors) were discharged from the hospital without anticoagulation [11], mainly because of a history of coumadin intolerance and fall risk. Similarly, Somerfield et al, reported that in a group of AF pa- tients admitted with stroke, 30% were not treated with coumadin because of fall risk and only 20% of these patients were on coumadin prior to that despite a known history of AF [12]. These and similar studies suggest that a significant proportion of high-risk AF patients are not considered to be candidates for coumadin therapy.…”

Long term treatment of atrial fibrillation in elderly patients: A decision analysis

“…Besides, the bleeding risk and the constrains associated with warfarin treatment are concerns in daily practice for many elderly patients: some are unable to comply with the required monitoring and dose adaptation, others fall frequently or have bled. Warfarin appears as underused in most practice surveys, where only a fraction (20 to 65%) of all theoretically eligible patients actually received it [9,10].…”

Antithrombotic therapy for atrial fibrillation in patients with acute ischemic stroke or transient ischemic attack

“…From August 2006 to December 2012, we prospectively recruited patients with acute ischemic stroke or TIA admitted to our hospital who met the following 3 criteria: (1) age 18 years or older, (2) had AF based on a 12-lead electrocardiogram obtained at admission, and (3) no rheumatic heart disease or prosthetic heart valve based on the patient's clinical history and echocardiographic examination. According to a predetermined protocol, the clinical data were collected from each patient.…”

“…Post-stroke severe disability and high risk of falls are common reasons for not using warfarin in patients with ischemic stroke and AF [2]. However, previous studies demonstrated that warfarin reduced post-stroke mortality in patients with AF, and this beneficial effect was independent of age and stroke severity [3,4].…”