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(Stroke. 2006;37:3052.)
© 2006 American Heart Association, Inc.

Controversies in Stroke

Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation

Yes

From the Stroke Unit, Department of Neurological Sciences, Instituto de Investigaciones Biomédicas August Pi I Sunyer (IDIBAPS), Hospital Clínic Barcelona, Spain.

Correspondence to Dr Ángel Chamorro, Stroke Unit, Department of Neurological Sciences, Instituto de Investigaciones Biomédicas August Pi I Sunyer (IDIBAPS), Hospital Clínic Barcelona, 170 Villarroel, 08036 Barcelona, Spain. E-mail chamorro@ub.edu

Geoffrey A. Donnan MD, FRACP Section Editors Stephen M. Davis MD, FRACP

Key Words: atrial fibrillation

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

Meta-analyses contest the value of "immediate" anticoagulation in acute stroke¹ although the trials included in these analyses referred to patients treated protractedly and the anticoagulants examined had significant pharmacological differences.² Post hoc analyses of some of these trials extend the overall negative effects of anticoagulation to patients with stroke secondary to atrial fibrillation (AF).³ The value of immediate anticoagulation in patients with acute stroke secondary to AF, alike its role in any other stroke subtype, has not been adequately explored. Thus, I agree that "delayed" anticoagulation is not beneficial for stroke attributable to AF, although I defend that to bring down the value of "immediate" anticoagulation is premature. Absence of evidence is not equal to evidence of absence.

Observational data suggest that full anticoagulation with unfractionated heparin (UH) started within <6 hours from clinical onset is better than delayed anticoagulation.⁴ The Rapid Anticoagulation Prevents Ischemic Damage (RAPID) trial is the closest randomized approach to immediate anticoagulation, with a mean treatment delay of 6.9 hours.⁵ Other trials delayed treatment for 24 (Trial of Org 10172 in Acute Stroke Treatment [TOAST], Fraxiparin in Stroke Study Bis [FISS bis]), 30 (Heparin in Acute Embolic Stroke Trial [HAEST]) or 48 hours (FISS, Tinzaparin in Acute Ischemic Stroke Trial [TAIST], International Stroke Trial [IST]), and some of them are also limited by unblinding of treatment, ill-timed use of CT, or ambiguous definitions of end points (ie, recurrent stroke). The RAPID trial confirmed the higher risk of bleeding by excessive anticoagulation.⁵ Therefore, the omission of monitoring . . . [Full Text of this Article]