Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals.
The optimal evaluation and management of patients with atrial fibrillation who suffer an acute ischemic stroke remains controversial.


METHODS
Medical records of 171 consecutive patients with atrial fibrillation and acute stroke at six U.S. university hospitals were reviewed. Data collected included the use of antithrombotic therapy, brain and cardiac imaging, bleeding complications, stroke risk factors, and contraindications to anticoagulation.


RESULTS
Mean age was 75.4 years. Cardiovascular risk factors associated with increased stroke risk were present in 87%; 35% had at least one contraindication to anticoagulation. Half of the patients with stroke risk factors and no contraindications to anticoagulation were not receiving any antithrombotic therapy at the time of admission. Of the 22 patients who were treated with warfarin, and had INR values on admission, 16 had levels of < 2.0; only six had INR values between 2.0 and 3.0. Transthoracic echocardiography was performed in 107 patients (63%); intracardiac thrombi were visualized in only 5%. Initial brain imaging revealed hemorrhagic transformation in nine. Heparin was used in 93 patients (54%), usually within 48 hours of stroke onset. Patients who received delayed heparin typically did not have repeat brain imaging prior to starting heparin. One patient had a delayed symptomatic cerebral hemorrhage. Of the survivors, 47% were discharged and treated with warfarin (or warfarin plus aspirin), 28% with ASA, 7% with other antithrombotic therapies, and 18% with no antithrombotic therapy.


CONCLUSIONS
Antithrombotic therapy was underutilized and inadequately monitored in atrial fibrillation patients prior to stroke onset. After hospital admission, a wide range of diagnostic and management strategies, which often did not follow current recommendations, were employed.
Albers
G W
GW
Stanford University Medical Center, Palo Alto, CA, USA.
Bittar
N
N
Young
L
L
Hattemer
C R
CR
Gandhi
A J
AJ
Kemp
S M
SM
Hall
E A
EA
Morton
D J
DJ
Yim
J
J
Vlasses
P H
PH
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001241:Aspirin / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology; D002561:Cerebrovascular Disorders / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology; D004452:Echocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000008:administration & dosage; D006785:Hospitals, University; D006801:Humans; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D012189:Retrospective Studies; D012307:Risk Factors; D013923:Thromboembolism / Q000150:complications / Q000175:diagnosis / Q000209:etiology; D014481:United States; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D006493:Heparin; D001241:Aspirin