Appropriate Anticoagulation Underutilized in Atrial fibrillation Interview with:
Dr. Ying Xian
Department of Neurology,
Duke Clinical Research Institute
Duke University Medical Center
Durham, North Carolina What is the background for this study?

Response: Atrial fibrillation (AF) is the most common arrhythmia. AF increases the risk for stroke and accounts for 10% to 15% of all ischemic strokes. While the burden of AF-related stroke is high, AF is a potentially treatable risk factor. Numerous studies have demonstrated that vitamin K antagonists, such as warfarin, or non-vitamin K antagonist oral anticoagulants (NOACs), reduce the risk of ischemic stroke. Based on these data, current guidelines recommend adjusted-dose warfarin or NOACs over aspirin for stroke prevention in high-risk patients with Atrial fibrillation. What are the main findings?

Response: Despite guideline recommendations, oral anticoagulants are often underused in clinical practice. In this study of 94,474 patients presenting with acute ischemic stroke who had a known history of Atrial fibrillation in the US, we found that only 16% were taking therapeutic anticoagulation such as NOACs or warfarin (INR≥2) prior to stroke. The vast majority (84%) were either taking antiplatelet therapy such as aspirin only (40%), not receiving any antithrombotic therapy at all (30%), or receiving sub-therapeutic warfarin (INR<2, 14%) before stroke. While some of these patients may have had reasons for not being anticoagulated, such as high bleeding or fall risk, more than two-thirds had no documented reason for receiving inadequate stroke prevention therapy. In the rare cases where therapeutic anticoagulation failed to prevent a stroke, patients who were taking NOACs or therapeutic warfarin tended to have less severe stroke, with less disability and death. What should readers take away from your report?

Response: These findings highlight the huge opportunities to reduce stroke and improve outcomes with the proper use of oral anticoagulants among eligible Atrial fibrillation patients. Broader adherence to these atrial fibrillation treatment guidelines could substantially reduce both the number and severity of strokes in the U.S. We estimate that between 58,000 to 88,000 strokes might be preventable per year if the treatment guidelines are followed appropriately. What recommendations do you have for future research as a result of this study?

Response: Given the huge missed opportunities for stroke prevention, future quality improvement efforts are needed to optimize care and outcomes in high-risk AF patients.

Disclosures: This study received funding support from the Patient-Centered Outcomes Research Institute. Thank you for your contribution to the community.


Xian Y, O’Brien EC, Liang L, Xu H, Schwamm LH, Fonarow GC, Bhatt DL, Smith EE, Olson DM, Maisch L, Hannah D, Lindholm B, Lytle BL, Pencina MJ, Hernandez AF, Peterson ED. Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation. JAMA. 2017;317(10):1057-1067. doi:10.1001/jama.2017.1371

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on March 14, 2017 by Marie Benz MD FAAD