title: Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes.
abstract: OBJECTIVE
  An increased risk of stroke was observed in two atrial fibrillation (AF) trials of oral factor Xa inhibitors, when patients were transitioned to open label warfarin at the end of the study. The objective of this study is to determine whether initiation of warfarin is associated with an increased risk of stroke in patients with AF.
  
  
  RESULTS
  Using the UK Clinical Practice Research Datalink, a nested case-control analysis was conducted within a cohort of 70 766 patients with AF between 1993 and 2008. Stroke cases were randomly matched with up to 10 controls on age, sex, date of AF diagnosis, and time since AF diagnosis. Conditional logistic regression was used to estimate adjusted rate ratios (RRs) with 95% confidence intervals (CIs) of stroke associated with current warfarin use classified according to time since initiation of treatment (<30 days, 31-90 days, and >90 days), when compared with non-use. A total of 5519 patients experienced a stroke during follow-up. Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR: 1.71, 95% CI: 1.39-2.12), while decreased risks were observed with initiation >30 days before the event (31-90 days: RR: 0.50, 95% CI: 0.34-0.75 and >90 days: RR: 0.55, 95% CI: 0.50-0.61, respectively).
  
  
  CONCLUSIONS
  Patients initiating warfarin may be at an increased risk of stroke during the first 30 days of treatment, supporting the biological plausibility of a transient hypercoagulable state at the start of the treatment, although additional studies are needed to confirm these findings.
authors.affiliation: Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte-Sainte-Catherine, H-461, Montreal, QC, Canada H3T 1E2 Department of Oncology, McGill University, Montreal, QC, Canada.
authors.forename: Laurent
authors.initials: L
authors.lastname: Azoulay
authors.affiliation: Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte-Sainte-Catherine, H-461, Montreal, QC, Canada H3T 1E2.
authors.forename: Sophie
authors.initials: S
authors.lastname: Dell'Aniello
authors.affiliation: Bristol-Myers Squibb, Princeton, NJ, USA.
authors.forename: Teresa A
authors.initials: TA
authors.lastname: Simon
authors.affiliation: Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte-Sainte-Catherine, H-461, Montreal, QC, Canada H3T 1E2 Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.
authors.forename: Christel
authors.initials: C
authors.lastname: Renoux
authors.affiliation: Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte-Sainte-Catherine, H-461, Montreal, QC, Canada H3T 1E2 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada samy.suissa@mcgill.ca.
authors.forename: Samy
authors.initials: S
authors.lastname: Suissa
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000150:complications*; D002545:Brain Ischemia / Q000139:chemically induced* / Q000517:prevention & control; D016022:Case-Control Studies; D057915:Drug Substitution; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D012307:Risk Factors; D020521:Stroke / Q000139:chemically induced* / Q000517:prevention & control; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D065427:Factor Xa Inhibitors; D014859:Warfarin
keywords: Atrial fibrillation; Hypercoagulable state; Population-based; Stroke; Warfarin