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(Stroke. 2009;40:5.)
© 2009 American Heart Association, Inc.

Editorials

Warfarin

An Inconvenient Truth

Melina Gattellari, PhD; John Worthington, MBBS Nicholas Zwar, PhD

From School of Public Health and Community Medicine (M.G., N.Z.), The University of New South Wales, Australia; the Centre for Research, Evidence Management and Surveillance (M.G.), Division of Population Health, Sydney South West Area Health Service, NSW, Australia; The Northern Beaches Stroke Service (J.W.), Sydney, NSW, Australia; Sydney South West Clinical School, The University of New South Wales and Liverpool Health Service, Liverpool, NSW, Australia.

Correspondence to John Worthington, Senior Staff Specialist, Department of Neurophysiology, Liverpool Health Service, Locked Bag 7017, Liverpool NSW 1871 Australia. E-mail John.Worthington@sswahs.nsw.gov.au

Key Words: atrial fibrillation • evidence-practice gaps • warfarin

An extract of the first 250 words of the full text is provided, because this article has no abstract.

See related article, pages 235–240.

In 1989, the Copenhagen AFASAK study¹ reported results from the first randomized, placebo-controlled trial evaluating adjusted-dose warfarin and aspirin in the prevention of stroke for nonvalvular atrial fibrillation (NVAF). Like the 5 randomized, placebo-controlled trials that came after it,² the Copenhagen AFASAK study demonstrated a reduction in embolic events in patients taking warfarin. Today, the weight of evidence from 18 trials comparing warfarin with either placebo or antiplatelet drugs overwhelmingly favors the use of warfarin for stroke prevention in NVAF.^2,3

In 20 years since AFASAK and 10 years since the first meta-analysis of trials testing the effect of warfarin on stroke risk,⁴ anticoagulation has remained underused and opportunities for preventing fatal and disabling stroke have been frequently missed.^5–12 In this issue of Stroke, Gladstone and colleagues⁵ report a prospective practice audit of 920 patients presenting with ischemic stroke and a history of atrial fibrillation to 12 hospitals in Ontario, Canada. All patients had a high risk of stroke. Approximately 60% of the 597 patients with a first-ever stroke were not receiving warfarin at the time of admission. Of those receiving warfarin, approximately three fourths had a subtherapeutic international normalized ratio (INR) recorded on admission. A further 323 patients with a history of stroke or transient ischemic attack arguably had the most to gain from warfarin. Approximately 40% of this group was not on warfarin at the time of admission, whereas 70% of those using warfarin had subtherapeutic INR levels. These findings are disturbing . . . [Full Text of this Article]

Related Article:

Potentially Preventable Strokes in High-Risk Patients With Atrial Fibrillation Who Are Not Adequately Anticoagulated

David J. Gladstone, Esther Bui, Jiming Fang, Andreas Laupacis, M. Patrice Lindsay, Jack V. Tu, Frank L. Silver, and Moira K. Kapral
Stroke 2009 40: 235-240. [Abstract] [Full Text] [PDF]