Not all patients with atrial fibrillation-associated ischemic stroke can be started on anticoagulant therapy.
OBJECTIVE
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 (P<0.001) and 23 (56%) were discharged to institutional care (P<0.001). 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.
Department of Neurology, Auckland City Hospital, Auckland, New Zealand.
Jennifer
J
Somerfield
P Alan
PA
Barber
Neil E
NE
Anderson
Ajay
A
Kumar
David
D
Spriggs
Alison
A
Charleston
Patricia
P
Bennett
Yvette
Y
Baker
Linda
L
Ross
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D055502:Secondary Prevention; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology* / Q000503:physiopathology; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin