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(Stroke. 2002;33:2722.)
© 2002 American Heart Association, Inc.

Comments, Opinions, and Reviews

Atrial Fibrillation, Stroke, and Acute Antithrombotic Therapy

Analysis of Randomized Clinical Trials

Robert G. Hart, MD; Santiago Palacio, MD Lesly A. Pearce, MS

From the Department of Medicine (Neurology), University of Texas Health Science Center, San Antonio (R.G.H., S.P.), and Minot, ND (L.A.P.).

Correspondence to Robert G. Hart, MD, Department of Medicine (Neurology), University of Texas Health Science Center, MSC 7883, 7703 Floyd Curl Dr, San Antonio, TX 78229-3900. E-mail hartr{at}uthscsa.edu

Background— Strokes in patients with atrial fibrillation (AF) are typically larger, are associated with higher early mortality, and occur in older patients versus strokes in patients with sinus rhythm. Until recently, the value of antithrombotic therapies for acute stroke management has been based on empiric evidence.

Summary of Review— We present a critical review of 3 randomized clinical trials testing aspirin, heparin/heparinoid, or both involving 5029 patients with AF and acute stroke. Early recurrent ischemic stroke occurred in about 5% of patients during the 2 to 4 weeks after initial stroke. Data conflict about whether early use of heparin/heparinoid reduced early recurrent ischemic stroke but are consistent regarding its lack of overall benefit on long-term functional outcome. Modest benefits for reduction of early recurrent stroke and functional outcome were associated with aspirin use, based largely on subgroup analysis from a single, large, unblinded trial.

Conclusions— No benefit of heparin has been demonstrated for acute stroke patients with AF; whether selected subgroups would respond differently remains to be proven. Aspirin followed by early initiation of warfarin for long-term secondary prevention is reasonable antithrombotic management.

Key Words: aspirin • atrial fibrillation • heparin • stroke • thrombolysis

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