Background: Stroke prevention with oral anticoagulation is effective in patients with atrial fibrillation. An additional beneficial effect of oral anticoagulation prior to the event on stroke severity and prognosis was suggested in ischemic strokes. We tested whether this benefit is preserved after inclusion of hemorrhagic strokes and adjustment for prestroke living conditions. Methods: Data were used from a prospective hospital-based intervention trial evaluating quality of care and outcome in ten district hospitals. All ischemic and hemorrhagic stroke patients with atrial fibrillation were included. We analyzed separate multivariable regression models to identify factors associated with prescription of oral anticoagulation before stroke and to investigate the independent effect of anticoagulation on admission stroke severity, 3-month mortality and functional outcome. Results: The analysis comprised 804 (718 ischemic, 86 hemorrhagic) stroke patients admitted between July 2003 and March 2005. Males, patients aged 65–84, living independently, with diabetes, previous cerebrovascular event or additional high cardioembolic risks were more likely to receive oral anticoagulation before admission. Admission international normalized ratio (INR) between 2 and 3 (OR 0.35, 95% CI: 0.17–0.71) or higher (OR 0.32, 95% CI: 0.11–0.92) was associated with less severe strokes (including hemorrhagic strokes) compared with INR <2. Anticoagulation was associated with decreased risk of death and poor functional outcome (modified Rankin Scale >3) at 3 months (OR 0.54, 95% CI: 0.36–0.84, and OR 0.70, 95% CI: 0.47–1.06). After adjustment for stroke severity, anticoagulation had no additional effect on mortality and functional outcome. Conclusions: The beneficial effect of prestroke anticoagulation on stroke outcome related to the reduced stroke severity is not offset by adverse effects in hemorrhagic stokes.

Background: Oral anticoagulation is highly effective for secondary prevention of cardioembolic strokes in patients with atrial fibrillation (AF). There are no studies investigating timing and complications of different strategies for initiation of oral anticoagulation after acute stroke or transient ischaemic attack (TIA). Methods: Patients of ten community hospitals participating in the prospective evaluation of medical effects of the Telemedical Project for Integrative Stroke Care (TEMPiS) were included. This observational evaluation was restricted to ischaemic stroke or TIA patients with AF who were started on Phenprocoumon treatment during in-hospital stay. Antithrombotic co-medication was dichotomized in heparin bridging (weight or partial thromboplastin time-adjusted heparin) or conventional treatment (antiplatelets and/or low-dose heparin or nil). Besides treatment-relevant extracranial bleeding, major complications were documented according to the European Atrial Fibrillation Trial definitions including vascular death, ischaemic or haemorrhagic stroke, systemic embolism, and myocardial infarction. Results: Between July 2003 and March 2005, 4,082 ischaemic stroke or TIA patients were admitted. AF was recorded in 961 patients (23.5%), of whom 376 (39.1%) received oral anticoagulation. In 229 of these patients oral anticoagulation was started in hospital, 150 (65.5%) with heparin bridging and 79 (34.5%) with conventional treatment. Patients with heparin bridging were younger, and had a longer in-hospital stay after adjustment for potential confounders (p = 0.01). Major complications were infrequent in both groups (2.0 vs. 2.5%; p = 1.0) as well as extracranial bleeding (3.3 vs. 1.2%; p = 0.43). Conclusions: Initiation of oral anticoagulation after acute ischaemic stroke yielded low complication rates independent of antithrombotic co-medication. Heparin bridging was associated with a longer stay in acute care hospitals.