Research Article| Volume 334, ISSUE 1-2, P139-142, November 15, 2013

Ischemic stroke in patients with atrial fibrillation receiving oral anticoagulation

Published:September 20, 2013DOI:



      Atrial fibrillation is the most common cause of embolic stroke associated to heart disease. Oral anticoagulation with vitamin K antagonists substantially reduces this risk.


      We assessed a group of patients with prior diagnosis of atrial fibrillation who sustained an ischemic stroke while receiving an adequate regime of oral anticoagulation.


      We evaluated consecutive patients with ischemic stroke and prior diagnosis of atrial fibrillation. We determined demographics, clinical characteristics, TOAST stroke subtypes, CHADS2 scores, and prior or concomitant use of oral anticoagulants.


      We studied 112 patients. Thirty nine of them (35%) had received an adequate dose of a vitamin K antagonist during the 24-hour period preceding the stroke. There were no differences in demographics, vascular risk factors, CHADS2 scores, nor medications use between patients who were or were not receiving anticoagulation. Other potential etiologies for stroke occurrence were found in 8 (21%) anticoagulated patients, and in 3 (4%) non-anticoagulated subjects (p < 0.01). Anticoagulated patients had a mean international normalized ratio (INR) of 2.3 ± 1.3 (median 2.05), and INR was within therapeutic ranges (i.e., ≥2) in 54% of these subjects.


      A substantial proportion of patients with atrial fibrillation who have an ischemic stroke are already receiving oral anticoagulation. Sub-optimal levels of anticoagulation and additional etiologies explain, only in part, this failure. Further research is needed to help find adequate therapeutic strategies in atrial fibrillation patients who sustain an ischemic stroke while receiving oral anticoagulation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • et al.
        Heart Disease and Stroke Statistics—2013 Update. A Report From the American Heart Association.
        Circulation. 2013; 127: e6-e245
        • Psaty B.M.
        • Manolio T.A.
        • Kuller L.H.
        • et al.
        Incidence of and risk factors for atrial fibrillation in older adults.
        Circulation. 1997; 96: 2455-2461
        • Wolf P.A.
        • Abbott R.D.
        • Kannel W.B.
        Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.
        Stroke. 1991; 22: 983-988
        • Hughes M.
        • Lip G.Y.
        Guideline Development Group, National Clinical Guideline for Management of Atrial Fibrillation in Primary and Secondary Care, National Institute for Health and Clinical Excellence. Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data.
        Thromb Haemost. 2008; 99: 295-304
        • Steger C.
        • Pratter A.
        • Martinek-Bregel M.
        • et al.
        Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry.
        Eur Heart J. 2004; 25: 1734-1740
        • Hart R.G.
        • Pearce L.A.
        • Aguliar M.I.
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Hart R.G.
        • Benavente O.
        • McBride R.
        • et al.
        Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.
        Ann Intern Med. 1999; 131: 492-501
        • Birman-Deych E.
        • Radford M.J.
        • Nilasena D.S.
        • et al.
        Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation.
        Stroke. 2006; 37: 1070-1074
        • Hylek E.M.
        • Evans-Molina C.
        • Shea C.
        • et al.
        Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation.
        Circulation. 2007; 115: 2689-2696
        • Connolly S.J.
        • Pogue J.
        • Eikelboom J.
        • et al.
        Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range.
        Circulation. 2008; 118: 2029-2037
        • Skanes A.C.
        • Healey J.S.
        • Cairns J.A.
        • et al.
        Focused 2012 update of the canadian cardiovascular society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control.
        Can J Cardiol. 2012; 28: 125-136
        • Furie K.L.
        • Goldstein L.B.
        • Albers G.W.
        • et al.
        Oral antithrombotic agents for the prevention of stroke in nonvalvular atrial fibrillation: a science advisory for healthcare professionals from the American Heart Association/AmericanStroke Association.
        Stroke. 2012; 43: 3442-3453
        • Eikelboom A.W.
        • Witz J.I.
        New anticoagulants.
        Circulation. 2010; 121: 1523-1532
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.V.
        • et al.
        Apixaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2011; 365: 981-993
        • Connolly J.S.
        • Ezekowitz M.D.
        • Yusuf S.
        • et al.
        Dabigatran versus Warfarin in Patients with Atrial Fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • et al.
        Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Adams Jr., H.P.
        • Bendixen B.H.
        • Kappelle L.J.
        • et al.
        Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. TOAST: Trial of Org 10172 in Acute Stroke Treatment.
        Stroke. 1993; 24: 35-41
        • Gage B.F.
        • Waterman A.D.
        • Shannon W.
        • et al.
        Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
        JAMA. 2001; 285: 2864-2870
        • Nieuwlaat R.
        • Olsson S.B.
        • Lip G.Y.
        • et al.
        Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation.
        Am Heart J. 2007; 153: 1006-1012
        • Kowey P.R.
        • Reiffel J.A.
        • Myerburg R.
        • et al.
        Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologist (from the AFFECTS Registry).
        Am J Cardiol. 2010; 105: 1130-1134
        • Labadet C.
        • Liniado C.
        • Ferreiros E.R.
        • et al.
        Resultados del Primer Estudio Nacional, Multicéntrico y Prospectivo de Fibrilación Auricular Crónica en la República Argentina.
        Rev Argent Cardiol. 2001; 69: 49-67
        • Pujol Lereis V.A.
        • Ameriso S.
        • Povedano G.P.
        • et al.
        Ischemic Stroke in Patients Receiving Aspirin.
        J Stroke Cerebrovasc Dis. 2011; 21: 868-872
        • Bungard T.J.
        • Ghali W.A.
        • Teo K.K.
        • et al.
        Why do patients with atrial fibrillation not receive warfarin?.
        Arch Intern Med. 2000; 160: 41-46
        • Connolly S.J.
        • Eikelboom J.
        • O’Donnell M.
        • et al.
        Challenges of establishing new antithrombotic therapies in atrial fibrillation.
        Circulation. 2007; 116: 449-455
        • Rose M.J.
        • Hylek E.M.
        • Ozonoff A.
        Risk-Adjusted Percent Time in Therapeutic Range as a Quality Indicator for Outpatient Oral Anticoagulation Results of the Veterans Affairs Study To Improve Anticoagulation (VARIA).
        Circ Cardiovasc Qual Outcomes. 2011; 4: 22-29
        • Reynolds M.W.
        • Fahrbach K.
        • Hauch O.
        • et al.
        Warfarin anticoagulation and outcomes in patients with atrial fibrillation: a systematic review and meta-analysis.
        Chest. 2004; 126: 1938-1945
        • Hart R.G.
        • Pearce L.A.
        • Miller V.T.
        • et al.
        Cardioembolic vs. noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the stroke prevention in atrial fibrillation studies.
        Cerebrovasc Dis. 2000; 10: 39-43
        • Chang Y.J.
        • Ryu S.J.
        • Lin S.K.
        Carotid artery stenosis in ischemic stroke patients with nonvalvular atrial fibrillation.
        Cerebrovasc Dis. 2002; 13: 16-20