Abstract Details

Title Ischemic Stroke in Patients with Atrial Fibrillation Failing Warfarin Therapy

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P06 - (-)

Poster/Presentation
Number 246

Objective

Background BACKGROUND: Patients with AF are educated on the risks of thromboembolic events and excess bleeding with inconsistent warfarin use but little is known about "warfarin failure" in patients with AF who are compliant with their regimen.

Design/Methods DESIGN/METHODS: Patients with ischemic stroke admitted to University Hospitals-Case Medical Center between 7/09-7/11 were retrospectively reviewed under IRB approval for warfarin use, compliance,level of anticoagulation, demographics and risk factors, interventions and medications on discharge. Stroke mechanism was classified using the TOAST calculator.

Results RESULTS: Consistent warfarin use was reported in only 21.2% (44/ 208) of patients presenting with ischemic stroke and AF; 31.8% of these were therapeutic (TINR) and 61.8% subtherapeutic (SINR) on treatment. TINR patients were significantly more likely to have valvular heart disease (28.5% vs 0%, p=0.003), hypertension(OR 3.4615 CI 0.37-31.56) and were younger, with higher CHADS2 scores (2.85 vs 2.63), more severe stroke (NIHSS 13.06 vs 10.26) and discharge to a facility (86 % vs 57%, p=0.06). There was no difference in the rates of prior stroke, diabetes or coronary disease. Stroke mechanism by TOAST criteria was cardioembolic in only half of patients (evident 14.2%, possible 35.7%), the remainder comprising lacunar (14.2%), large artery atherosclerosis (7.1%), and cryptogenic (28.5%) mechanisms. Management strategies included discharge on adjusted dose warfarin (62%), alternative oral anticoagulant (8%), carotid stent (8%), and discontinuation of warfarin (23%) due to bleeding complications during the hospitalization.

Conclusions CONCLUSIONS: There are no recommendations in the guidelines for patients with AF and stroke failing warfarin therapy. For patients with valvular disease, the intensity of anticoagulation can be increased, however alternative causes may account for a significant proportion of strokes in these patients and recommendations for therapy should be individualized based upon a thorough evaluation.

Authors/Disclosures
Prachi Mehndiratta, MD PRESENTER	Dr. Mehndiratta has nothing to disclose.
Murad M. Talahma, MD (Ochsner Medical Center)	No disclosure on file
Cathy A. Sila, MD, FAAN (Neurological Institute Cleveland Medical Center)	Dr. Sila has nothing to disclose.
Tanuja Chitnis, MD, FAAN (Brigham and Women's Hospital)	Dr. Chitnis has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Novartis. Dr. Chitnis has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Roche-Genentech. Dr. Chitnis has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Octave Biosciences. Dr. Chitnis has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Sanofi. The institution of Dr. Chitnis has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis. The institution of Dr. Chitnis has received research support from Novartis. The institution of Dr. Chitnis has received research support from Sanofi. The institution of Dr. Chitnis has received research support from Octave. The institution of Dr. Chitnis has received research support from Genentech-Roche. The institution of Dr. Chitnis has received research support from Tiziana Life Sciences. The institution of Dr. Chitnis has received research support from Bristol-Myers Squibb. The institution of Dr. Chitnis has received research support from Wesley Clover.

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