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Stroke
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my personal edition > stroke > news
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DGReview
Anticoagulation Therapy Reduces Stroke Frequency, Severity, and Mortality in Patients with Atrial Fibrillation
New England Journal of Medicine (NEJM)
09/11/2003
By Joene Hendry
Oral anticoagulation therapy to an international normalised ratio (INR) of 2.0 or greater reduces the frequency and severity of ischaemic stroke, as well as the risk of stroke-related death among patients with nonvalvular atrial fibrillation according to an observational study of a large cohort of patients.
"Our data indicate that an INR of less than 2.0 will substantially increase the likelihood of death and severe disability from atrial fibrillation-related stroke," writes Elaine M. Hylek, MD, MPH, Massachusetts General Hospital, Harvard Medical School, Boston, United States and colleagues. They calculated incident ischaemic strokes in 13,559 patients with nonvalvular atrial fibrillation and the use of aspirin, no anticoagulant, or warfarin and the associated INR, as well as stroke severity and 30-day mortality in the cohort. The mean age of the patients was 78 years, 55% were women, nearly 70% of the cohort had hypertension, and about one-third had a history of congestive heart failure, coronary heart disease, or stroke.
Among the 596 patients who experienced an ischaemic stroke, 248 (42%) were taking neither aspirin nor warfarin at the time of their stroke. Of these 22% died before discharge or were discharged with a severe deficit.
Of the 160 (27%) patients taking aspirin at the time of their stroke, 13% died before discharge or had a severe deficit upon discharge.
Among the 188 (32%) patients taking warfarin at the time of their stroke, the investigators report a median INR upon admission of 1.7. Overall, 62% of the warfarin users had INR values less than 2.0. Death or severe deficit was reported in 15% of the warfarin users with an INR value less than 2.0. Conversely, the warfarin users with an INR value of 2.0 or greater, 5% died before discharge or had a severe stroke-related deficit.
The 30-day mortality rate for warfarin patients with INR values of 2.0 or greater was 6%. These rates were significantly higher among the other groups " 16% for warfarin users with INR values of 2.0 or less, 15% for aspirin users, and 24% for those not using aspirin or warfarin.
"Our findings highlight an important incremental benefit of anticoagulation," Dr. Hylek and colleagues write, "strokes that occur among patients with adequate anticoagulation are far less likely to result in severe disability or death."
N Engl J Med 2003; 349:11:1013-1014.
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