An Analysis of the Lowest Effective Intensity of Prophylactic Anticoagulation for Patients with Nonrheumatic Atrial Fibrillation

Hylek, Elaine M.; Skates, Steven J.; Sheehan, Mary A.; Singer, Daniel E.

doi:10.1056/nejm199608223350802

Cited by 757 publications

(447 citation statements)

References 28 publications

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“…In addition, 290 participants in the SPAF III randomized trial who were assigned to aspirin plus fixed, low-dose warfarin (mean daily doseϭ2.1 mg) and whose international normalized ratios (INRs) during follow-up were Յ1.4 were also included. 2 This latter group was included because INRs Ͻ1.5 have been shown to have no substantial effect on stroke prevention in AF, 2,13,14 and these high-risk participants were observed to have a stroke rate of 12.3%/y, similar to that expected during treatment with aspirin alone. 6 Those with "lone" AF (ie, no associated cardiovascular disease) aged Ͻ60 years were excluded.…”

Section: Methodsmentioning

confidence: 99%

Factors Associated With Ischemic Stroke During Aspirin Therapy in Atrial Fibrillation

Hart

Pearce²,

McBride³

et al. 1999

Stroke

461

126

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on behalf of the Stroke Prevention in Atrial Fibrillation (SPAF) InvestigatorsBackground and Purpose-Nonvalvular atrial fibrillation (AF) is a strong, independent risk factor for stroke, but the absolute rate of stroke varies widely among AF patients, importantly influencing the potential benefit of antithrombotic prophylaxis. We explore factors associated with ischemic stroke in AF patients taking aspirin. Methods-We performed multivariate logistic regression analysis of 2012 participants given aspirin alone or in combination with low, inefficacious doses of warfarin in the Stroke Prevention in Atrial Fibrillation I-III trials followed for a mean of 2.0 years, during which 130 ischemic strokes were observed. Pϭ0.007). With the use of these variables, a risk stratification scheme for primary prevention separated participants into those with high (7.1%/y, 22% of the cohort), moderate (2.6%/y, 37% of the cohort), and low (0.9%/y, 41% of the cohort) rates of stroke. Ischemic strokes in low-risk participants were less often disabling (PϽ0.001). Conclusions-Patients with AF who have high and low rates of stroke during treatment with aspirin can be identified.However, validation of our risk stratification scheme is necessary before it can be applied with confidence to clinical management. Postmenopausal estrogen replacement therapy and moderate alcohol consumption may additionally modify the risk of stroke in AF, but these findings require confirmation. (Stroke. 1999;30:1223-1229.)

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Section: Methodsmentioning

confidence: 99%

Factors Associated With Ischemic Stroke During Aspirin Therapy in Atrial Fibrillation

Hart

Pearce²,

McBride³

et al. 1999

Stroke

461

126

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“…The optimal INR was studied retrospectively in the EAFT participants who had been randomized to anticoagulation, 43 as well as in a case-control study of patients with AF. 44 Among the EAFT participants, the optimal INR was from 2.0 to 3.9. 43 In the case-control study, the risk of stroke rose steeply below an INR of 2.0.…”

Section: Discussionmentioning

confidence: 99%

“…43 In the case-control study, the risk of stroke rose steeply below an INR of 2.0. 44 A meta-analysis aimed at defining the relation between adverse events and INR suggests that the optimal INR depends on the patient's risk factors for stroke. 45 Efforts to refine the management of a patient's INR with the use of anticoagulation clinics may result in better outcomes, 46 as may home monitoring systems for measuring prothrombin times.…”

Section: Discussionmentioning

confidence: 99%

Prevention of thromboembolism in atrial fibrillation

et al. 2000

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OBJECTIVE: Appropriate use of drugs to prevent thromboembolism in patients with atrial fibrillation (AF) involves comparing the patient's risk of stroke and risk of hemorrhage. This review summarizes the evidence regarding the efficacy of these medications. METHODS:We conducted a meta-analysis of randomized controlled trials of drugs used to prevent thromboembolism in adults with nonpostoperative AF. Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until May 1998. A trial fibrillation (AF) is an increasingly common cardiac dysrhythmia affecting over 2 million people in the United States. 1-3 Restoration of sinus rhythm may involve consultation with a cardiologist; however, the prevention of cardioembolic events in patients who remain in AF falls within the domain of the primary care physician. 4 With a recently estimated 3.9 million office visits yearly for patients with AF, 5 internists need to aware of the current evidence regarding prevention of thromboembolic disease in order to provide the best care for their patients. MAIN RESULTS:The estimate that only one third of patients in AF are receiving warfarin is remarkably consistent across studies, 4,6-8 and has raised concerns that warfarin is greatly underutilized in patients with chronic AF. However, for interventions like warfarin that involve significant trade-offs, clinicians need a reliable synthesis of information on risks and benefits in order to make appropriate recommendations to patients. Therefore, we reviewed all of the randomized controlled trials involving anticoagulants and antiplatelet agents in the prevention of thromboembolism in patients with AF. Our aim was to evaluate the strength of the evidence on the efficacy and safety of the drugs used for the prevention of thromboembolic complications in adults with nonpostoperative AF and to report this information in a format useful to clinicians.

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“…3 Goal INR. Maintaining INR 84 levels within a range of 2.0 to 3.0 minimizes the incidence of both ischemic and hemorrhagic stroke 3,93,94 (Figure 3). The crucial relationship between low INR levels (below 2.0) and an increased risk of ischemic stroke was confirmed by the results of the AFFIRM trial: 72% of the 157 patients who experienced ischemic strokes during the trial had INR levels below 2.0 near the time of the strokes.…”

Section: Preventing Stroke In Patients With Afmentioning

confidence: 99%

Contemporary Management of Atrial Fibrillation: Update on Anticoagulation and Invasive Management Strategies

Crandall

Bradley

Packer

et al. 2009

Mayo Clinic Proceedings

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An Analysis of the Lowest Effective Intensity of Prophylactic Anticoagulation for Patients with Nonrheumatic Atrial Fibrillation

Cited by 757 publications

References 28 publications

Factors Associated With Ischemic Stroke During Aspirin Therapy in Atrial Fibrillation

Factors Associated With Ischemic Stroke During Aspirin Therapy in Atrial Fibrillation

Prevention of thromboembolism in atrial fibrillation

Contemporary Management of Atrial Fibrillation: Update on Anticoagulation and Invasive Management Strategies

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