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(Stroke. 2006;37:3054.)
© 2006 American Heart Association, Inc.

Controversies in Stroke

Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation

No

From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.

Correspondence to Peter Sandercock, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK. E-mail pags@skull.dcn.ed.ac.uk

Key Words: atrial fibrillation

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

"No benefit of heparin has been demonstrated for acute stroke patients with AF [atrial fibrillation]; 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."¹

The quote above is the conclusion of a careful review of the randomized trial evidence that was available in 2002, yet it is clear that many physicians and neurologists still cling to the nonevidence-based habit of giving intravenous heparin for acute ischemic stroke associated with AF.^2–5 While some dispute the validity of the trial evidence,^5,6 there are others who accept that there is no evidence of net benefit from heparin in this setting.^1,3,7 Indeed the American Stroke Association/American Academy of Neurology scientific statement on the subject concludes, "IV, unfractionated heparin or high-dose LMW heparin/heparinoids are not recommended for any specific subgroup of patients with acute ischemic stroke that is based on any presumed stroke mechanism or location (eg, cardioembolic, large vessel atherosclerotic, vertebrobasilar, or ‘progressing’ stroke) because data are insufficient (Grade U)."⁸

Because this high-quality practice guideline concludes there is no reliable evidence to support immediate anticoagulation, it is worth examining the determinants of current clinical practice. A survey of 36 US academic medical centers showed that 29% of a sample of 497 patients with acute ischemic stroke were treated with intravenous heparin, but the proportion-treated varied enormously between centers; from "not at all" in 7 centers to 88% in 1 center.² A survey of opinion among 280 neurologists from . . . [Full Text of this Article]