title: Thirty-day mortality after ischemic stroke and intracranial hemorrhage in patients with atrial fibrillation on and off anticoagulants.
abstract: OBJECTIVE
  Prescribing warfarin for atrial fibrillation depends in large part on the expected reduction in ischemic stroke risk versus the expected increased risk of intracranial hemorrhage (ICH). However, the anticoagulation decision also depends on the relative severity of such events. We assessed the impact of anticoagulation on 30-day mortality from ischemic stroke versus ICH in a large community-based cohort of patients with atrial fibrillation.
  
  
  METHODS
  We followed 13,559 patients with atrial fibrillation enrolled in an integrated healthcare delivery system for a median 6 years. Incident ischemic strokes and ICHs were identified from computerized databases and validated through medical record review. The association of warfarin and international normalized ratio at presentation with 30-day mortality was modeled using multivariable logistic regression adjusting for clinical factors.
  
  
  RESULTS
  We identified 1025 incident ischemic strokes and 299 ICHs during follow-up. Compared with no antithrombotic therapy, warfarin was associated with reduced Rankin score and lower 30-day mortality from ischemic stroke (adjusted OR, 0.64; 95% CI, 0.45-0.91) but a higher mortality from ICH (OR, 1.62; 95% CI, 0.88-2.98). Therapeutic international normalized ratios (2-3) were associated with an especially low ischemic stroke mortality (OR, 0.38; 95% CI, 0.20-0.70), whereas international normalized ratios>3 increased the odds of dying of ICH by 2.66-fold (95% CI, 1.21-5.86).
  
  
  CONCLUSIONS
  Warfarin reduces 30-day mortality from ischemic stroke but increases ICH-related mortality. Both effects on event severity as well as on event rates need to be incorporated into rational decision-making about anticoagulants for atrial fibrillation.
authors.affiliation: Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, Box 0131, San Francisco, CA 94143, USA. mfang@medicine.ucsf.edu
authors.forename: Margaret C
authors.initials: MC
authors.lastname: Fang
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: Leila H
authors.initials: LH
authors.lastname: Borowsky
authors.forename: Niela K
authors.initials: NK
authors.lastname: Pomernacki
authors.forename: Natalia
authors.initials: N
authors.lastname: Udaltsova
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Singer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000401:mortality*; D002545:Brain Ischemia / Q000188:drug therapy / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020300:Intracranial Hemorrhages / Q000188:drug therapy / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy / Q000401:mortality*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
chemical_list: D000925:Anticoagulants