title: Antithrombotic treatment at onset of stroke with atrial fibrillation, functional outcome, and fatality: a systematic review and meta-analysis.
abstract: BACKGROUND
  In atrial fibrillation-associated stroke, conflicting data exist regarding association between therapeutic vitamin K-antagonist anticoagulation (International Normalized Ratio 2-3) and early death and functional outcome, and few data exist relating to late outcome in ischemic and haemorrhagic atrial fibrillation-stroke.
  
  
  OBJECTIVE
  We performed a systematic review and meta-analysis of oral anticoagulation at stroke onset, death and functional outcome.
  
  
  METHODS
  We performed a systematic review, searching multiple sources. Studies were included if outcomes in atrial fibrillation-associated stroke were reported stratified by pre-stroke antithrombotic status, with documented International Normalized Ratio at onset. Outcomes were survival and good functional outcome (modified Rankin score 0-2) at discharge/30 days, and at one-year.
  
  
  RESULTS
  Of eight studies (3552 patients) in ischemic stroke, International Normalized Ratio ≥ 2 compared with other treatments (International Normalized Ratio < 2, antiplatelet, or no antithrombotic) was associated with good outcome [pooled odds ratio 1·9 (95% confidence interval) 1·5-2·5, P < 0·001] and improved survival at 30 days discharge (pooled odds ratio for death 0·4, confidence interval 0·2-0·5, P < 0·001). The net benefit remained after inclusion of haemorrhagic stroke (odds ratio for good outcome 1·89, confidence interval 1·45-2·46, P < 0·001). At one-year, improved functional outcome for International Normalized Ratio ≥ 2 (pooled odds ratio 1·7, confidence interval 1·0-2·7, P = 0·04) and survival (odds ratio for death 0·5, confidence interval 0·4-0·8, P = 0·001) were also observed.
  
  
  CONCLUSIONS
  Therapeutic International Normalized Ratio at stroke onset was associated with early and late improved survival and functional recovery suggesting sustained benefit for warfarin anticoagulation for stroke outcome in atrial fibrillation patients. Long-term outcome data following stroke in patients taking new oral anticoagulants is required.
authors: Neurovascular Unit for Neurovascular Unit for Translational and Therapeutics Research, UCD/DAMC, Dublin, Ireland.
authors: Niamh
authors: N
authors: Hannon
authors: Massachusetts General Hospital, Boston, MA, USA.
authors: Ethem M
authors: EM
authors: Arsava
authors: Charité Universitätsmedizin, Berlin, Germany.
authors: Heinrich J
authors: HJ
authors: Audebert
authors: Massachusetts General Hospital, Boston, MA, USA.
authors: Hakan
authors: H
authors: Ay
authors: St Vincents University Hospital, Dublin, Ireland.
authors: Morgan
authors: M
authors: Crowe
authors: Neurovascular Unit for Neurovascular Unit for Translational and Therapeutics Research, UCD/DAMC, Dublin, Ireland.
authors: Danielle
authors: D
authors: Ní Chróinín
authors: Massachusetts General Hospital, Boston, MA, USA.
authors: Karen
authors: K
authors: Furie
authors: Neurovascular Unit for Neurovascular Unit for Translational and Therapeutics Research, UCD/DAMC, Dublin, Ireland.
authors: Catherine
authors: C
authors: McGorrian
authors: Chaim Sheba Medical Center & Tel Aviv University, Tel Aviv, Israel.
authors: Noa
authors: N
authors: Molshatzki
authors: Neurovascular Unit for Neurovascular Unit for Translational and Therapeutics Research, UCD/DAMC, Dublin, Ireland.
authors: Sean
authors: S
authors: Murphy
authors: St Vincents University Hospital, Dublin, Ireland.
authors: Imelda
authors: I
authors: Noone
authors: McMaster University, Hamilton, ON, Canada.
authors: Martin
authors: M
authors: O'Donnell
authors: Klinikum Harlaching, Städtisches Klinikum München GmbH, Munich, Germany.
authors: Johannes
authors: J
authors: Schenkel
authors: St Vincents University Hospital, Dublin, Ireland.
authors: Kit M
authors: KM
authors: Tan
authors: Chaim Sheba Medical Center & Tel Aviv University, Tel Aviv, Israel.
authors: David
authors: D
authors: Tanne
authors: Neurovascular Unit for Neurovascular Unit for Translational and Therapeutics Research, UCD/DAMC, Dublin, Ireland.
authors: Peter J
authors: PJ
authors: Kelly
mesh_terms: D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D020127:Recovery of Function / Q000187:drug effects; D020521:Stroke / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D015912:Thrombolytic Therapy / Q000379:methods; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: anticoagulation; atrial fibrillation; prevention; stroke; warfarin