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(Stroke. 2006;37:1217.)
© 2006 American Heart Association, Inc.

Original Contributions

Not All Patients With Atrial Fibrillation–Associated Ischemic Stroke Can Be Started on Anticoagulant Therapy

Jennifer Somerfield, MBChB; P. Alan Barber, PhD, FRACP; Neil E. Anderson, FRACP; Ajay Kumar, FRACP; David Spriggs, FRACP; Alison Charleston, FRACP; Patricia Bennett, RN; Yvette Baker, RN Linda Ross, RN

From the Departments of Neurology (J.S., P.A.B., N.E.A., P.B., Y.B., L.R.) and Medicine (D.S.), Auckland City Hospital, and Geriatric Medicine, Auckland City Hospital (A.C.) and Middlemore Hospital (A.K.), Auckland, New Zealand.

Correspondence to Dr Alan Barber, Director, Auckland City Hospital Stroke Service, Park Rd, Grafton, Auckland 1001, New Zealand. E-mail abarber{at}adhb.govt.nz

Background and Purpose— 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.

Key Words: anticoagulants • atrial fibrillation • stroke, ischemic • warfarin

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