Among patients with AF ≥90 years of age, warfarin was associated with a lower risk of ischemic stroke and positive net clinical benefit. Compared with warfarin, NOACs were associated with a lower risk of ICH. Thus, OACs may still be considered as thromboprophylaxis for elderly patients, with NOACs being the more favorable choice.

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In this AF cohort, the authors demonstrated that the CHADS-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHADS-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.

A trial fibrillation (AF) represents an important risk factor of ischemic stroke, 1,2 and stroke prevention with oral anticoagulants (OACs) is the cornerstone for the management of AF. Treatment with vitamin K antagonists (eg, warfarin) effectively reduces the risk of stroke by 64% in comparison with placebo/control. 3 However, warfarin-related bleeding is the leading cause of emergent hospitalizations for adverse drug events in the elderly. 4 Among warfarin-related bleeding events, intracranial hemorrhage (ICH) is the most devastating complication, with an in-hospital mortality rate as high as 22%. 5,6 The efficacy and safety of warfarin is closely related to the quality of anticoagulation control, as reflected by the time in therapeutic range (TTR) with a TTR>70% being recommended. 7,8 Concerns about ICH could lead physicians to withhold OACs for some AF patients despite a high stroke risk, especially in Asian patients where the prevalence of ICH is much higher than in non-Asians, and the quality of anticoagulation control (ie, TTR) may be suboptimal. Clinical Perspective on p 1547In recent years, several non-vitamin K antagonist OACs (NOACs) have been demonstrated to be at least as effective Background-The risk of further intracranial hemorrhage (ICH) and the benefit of stroke risk reduction with the use of oral anticoagulants for patients who have atrial fibrillation with a history of ICH remain unclear. We aimed to investigate the risks and benefits in patients who have atrial fibrillation with a previous ICH treated with warfarin or antiplatelet drugs in comparison with no antithrombotic therapies. Methods and Results-This study used the National Health Insurance Research Database in Taiwan. Among 307 640 patients who have atrial fibrillation with a CHA 2 DS 2 -VASc score ≧2, 12 917 patients with a history of ICH were identified and were assigned to 1 of 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Among patients with previous ICH, the rate of ICH and ischemic stroke in untreated patients was 4.2 and 5.8 per 100 person-years, respectively. The annual ICH and ischemic stroke rates in warfarin users were 5.9% and 3.4%, respectively. Among users of antiplatelet agents, the rates were 5.3% per year and 5.2% per year, respectively. The number needed to treat for preventing 1 ischemic stroke was lower than the number needed to harm for producing 1 ICH with warfarin use for patients with a CHA 2 DS 2 -VASc score ≧6 (37 versus 56). The number needed to treat was higher than the number needed to harm for patients with a CHA 2 DS 2 -VASc score <6 (63 versus 53 11,12 Therefore, the risk of further ICH and the benefit of stroke risk reduction by the use of OACs remains unclear for AF patients with a history of ICH, and the appropriate strategy about stroke prevention by using OACs for these patients remains unknown.Our objective is to investigate the risks and benefits in AF patients with previous ICH treated with warfarin, in comparison with antiplatelet or no antithrombotic therapies, ...

BackgroundPatients with liver cirrhosis have been excluded from randomized clinical trials of oral anticoagulation therapy for stroke prevention in atrial fibrillation. We hypothesized that patients with liver cirrhosis would have a positive net clinical benefit for oral anticoagulation when used for stroke prevention in atrial fibrillation.Methods and ResultsThis study used the National Health Insurance Research Database in Taiwan. Among 289 559 atrial fibrillation patients aged ≥20 years, there were 10 336 with liver cirrhosis, and 9056 of them having a CHA 2 DS 2‐VASc score ≥2 were divided into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Patients with liver cirrhosis had a higher risk of ischemic stroke (hazard ratio=1.10, P=0.046) and intracranial hemorrhage (hazard ratio=1.20, P=0.043) compared with those without. Among patients with liver cirrhosis, patients taking antiplatelet therapy had a similar risk of ischemic stroke (hazard ratio=1.02, 95%CI=0.88‐1.18) compared to those without antithrombotic therapies, but the risk was significantly lowered among warfarin users (hazard ratio=0.76, 95%CI=0.58‐0.99). For intracranial hemorrhage, there were no significant differences between those untreated and those taking antiplatelet therapy or warfarin. The use of warfarin was associated with a positive net clinical benefit compared with being untreated or receiving only antiplatelet therapy.ConclusionsFor atrial fibrillation patients with liver cirrhosis in the current analysis of an observational study, warfarin use was associated with a lower risk of ischemic stroke and a positive net clinical benefit compared with nontreatment, and thus, thromboprophylaxis should be considered for such patients.