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Should stroke subtype influence anticoagulation decisions to prevent recurrence in stroke patients with atrial
1Department of Medicine, Guy's, King's & St Thomas' School of Medicine, King's College, London, UK. andy.evans@kcl.ac.uk
Insights
Warfarin is superior to aspirin for preventing cardioembolic stroke recurrence in atrial fibrillation patients. However, for lacunar stroke, aspirin and warfarin showed similar recurrence rates, suggesting stroke subtype influences treatment decisions.
Area of Science:
- Neurology
- Cardiology
- Internal Medicine
Background:
- Atrial fibrillation (AF) necessitates long-term anticoagulation for secondary stroke prevention.
- Current practice often uses anticoagulation regardless of stroke subtype.
- Warfarin's efficacy is established for cardioembolic stroke, but its benefit in other subtypes remains unclear.
Purpose of the Study:
- To compare the efficacy of warfarin versus aspirin in secondary stroke prevention among AF patients.
- To investigate the influence of stroke subtype on the effectiveness of anticoagulation versus antiplatelet therapy.
Main Methods:
- A 2-year prospective study of 386 acute stroke patients with AF.
- Patients were classified by stroke subtype using clinical and imaging criteria.
- Treatment involved adjusted-dose warfarin (INR 2.0-3.0) or aspirin (75-300 mg/d).
Main Results:
- Warfarin (n=214) showed a lower recurrent stroke rate (4.9%) compared to aspirin (n=172) (9.5%), P<0.02.
- Aspirin was associated with lower major bleeding rates (0.6% vs. 2.5%), P<0.05.
- The higher stroke rate with aspirin was mainly due to cardioembolic recurrence (8.4% vs. 1.9% in warfarin, P<0.01); lacunar stroke recurrence rates were similar (8.8% vs. 8.9%).
Conclusions:
- Anticoagulation with warfarin is more effective than aspirin in preventing cardioembolic stroke recurrence in AF patients.
- Aspirin and warfarin demonstrated comparable efficacy for preventing lacunar stroke recurrence.
- Stroke subtype determination is crucial for optimizing anticoagulation strategies in secondary stroke prevention.
Background And Purpose:
Long-term anticoagulation is routinely used for secondary stroke prevention in atrial fibrillation, often regardless of stroke subtype. Although the role of warfarin in cardioembolic stroke is established, it may not prevent recurrence in other stroke subtypes, even in the presence of atrial fibrillation.
Methods:
This was a 2-year, prospective, intervention study conducted in a district general hospital. Participants included 386 acute stroke patients with atrial fibrillation. Subjects were characterized for stroke subtype on clinical, neuroimaging, carotid ultrasonographic, and echocardiographic criteria. Eligible patients were treated with adjusted-dose warfarin (international normalized ratio, 2.0 to 3.0). Aspirin (75 to 300 mg/d) was used in patients with contraindications or those who refused anticoagulation. The main outcome measures were rate of recurrent stroke by subtype and major and minor bleeding complications.
Results:
The aspirin group (n=172) was comparable to the warfarin group (n=214) in terms of age, sex, risk factors, and initial stroke subtype. The rate of recurrent stroke was higher (9.5% versus 4.9%, P<0.02) but that of major bleeding was lower (0.6% versus 2.5%, P<0.05) with aspirin. The increased stroke rate with aspirin was due predominantly to cardioembolic recurrence in patients presenting initially with cardioembolic stroke (8.4% versus 1.9%, P<0.01). The recurrence rate in aspirin-treated patients who presented with lacunar stroke and atrial fibrillation was similar to that seen in patients receiving warfarin (8.8% versus 8.9%).
Conclusions:
In this cohort of stroke patients with atrial fibrillation, anticoagulation was superior to aspirin in preventing cardioembolic but not lacunar recurrence. Determination of stroke subtype may be important in anticoagulation decisions for secondary prevention, and further studies are required.