AF-related Stroke Research Articles

Abstract WP302: Atrial Fibrillation First Diagnosed at the Time of Ischemic Stroke: A Missed Opportunity

Introduction: Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke risk reduction afforded by oral anticoagulant therapy. In 1983 Wolf documented that 24% (95% CI 14-37) of AF-related strokes had AF first diagnosed at the time of stroke. Given increased medical and lay attention to AF-stroke, we sought to determine whether this percentage had decreased in contemporary care. Hypothesis: Less than 20% of patients with AF-related stroke have their AF first diagnosed at the time of stroke. Methods: We identified patients admitted to Massachusetts General Hospital from 01-01-2010 to 12-31-2013 with a new ischemic stroke and either previously or newly diagnosed AF by searching comprehensive hospital databases for stroke and AF ICD-9 codes in conjunction with a hospital stroke registry. Physician reviewers screened 1037 potentially eligible patients, categorized AF as previously known or newly diagnosed, and performed a structured chart review of the stroke event. To confirm the diagnosis of AF was new, we conducted automated searches for AF terms in the patients’ electronic medical records (EMRs) prior to the stroke admission. Results: We validated 856 cases (83%) as AF and ischemic stroke. AF was considered newly diagnosed in 156/856 (18%; 95%CI: 16-21). In the newly diagnosed group, no patient was on oral anticoagulants and the strokes were consequential (median NIHSS=12; 60% with mRankin of ≥3 at discharge, including 15% deaths). Pre-stroke CHA 2 DS 2 -VASc score was ≥2 in 89%. About half (76/156) had a prior medical encounter in the EMR. Evidence of pre-stroke AF was found in 8/76 records, often peri-procedural, but the AF diagnosis was not carried forward. Conclusions: In this large, contemporary cohort, nearly one in five AF-related strokes occurred in patients who did not carry a pre-stroke AF diagnosis, similar to Wolf’s 1983 finding. The vast majority would have been at high enough pre-stroke risk to merit anticoagulation. Our findings support screening for AF in patients before they have strokes. Further, patients with past transient AF identified via automated EMR searches might merit more intensive screening.

Abstract TP224: CHA2DS2-VASc Scores Are Correlated With Left Atrial Enlargement in Patients With Non-valvular Atrial Fibrillation-related Stroke

Background: In patients with non-valvular atrial fibrillation (NVAF), the CHA2DS2-VASc risk factors (Congestive heart failure, Hypertension, Age, Diabetes, prior Stroke/transient ischemic attack, vascular disease, female sex) are known to be associated with developing ischemic stroke. However, the mechanisms how the CHA2DS2-VASc risk factors increase the risk of ischemic stroke in NVAF has not been well understood in terms of the pathophysiologies of thrombogenesis. Virchow’s triad, including atrial tissue damage, hypercoagulable state, and blood stasis, was proposed to play a role in the pathophysiologic mechanism of thrombogenesis in NVAF, and blood stasis in AF occurs not only because of loss of atrial systole but also in relation to left atrial dilatation. The aim of this study was to evaluate the relationship between CHA2DS2-VASc risk factors and left atrial enlargement. We also assessed which factors among the CHA2DS2-VASc risk factors are most contributable to left atrial enlargement. Methods: Consecutive patients with acute ischemic stroke and NVAF who were anticoagulation-naïve were enrolled. Left atrial volume (LAV) and left atrial volume index (LAVI) were assessed using the biplane area-length method, following the American Society of Echocardiography standard guidelines. The association between CHA2DS2-VASc risk factors and left atrial enlargement were assessed. The contribution of each individual burden of CHA2DS2-VASc risk factors to left atrial enlargement was also evaluated. Results: A total of 98 patients who presented with acute ischemic stroke due to NVAF were enrolled. Correlation analysis showed that total CHA2DS2-VASc score was significantly correlated with left atrial volume index (r=0.33, p=0.002). The regression analysis showed that hypertension (t=0.25, p=0.014), congestive heart failure (t=0.20, p=0.045) and peripheral vascular disease (t=0.39, p<0.001) among the CHA2DS2-VASc scores were associated with left atrial enlargement. Conclusion: The CHA2DS2-VASc scores, particularly hypertension, congestive heart failure and peripheral vascular disease, were associated left atrial enlargement (LAE) in patients with acute ischemic stroke due to NVAF.

Improving Patient Outcomes in Preventing Atrial Fibrillation-related Stroke with Non-Vitamin K Antagonist Oral Anticoagulants

The rising incidence of atrial fibrillation (AF) is increasingly resulting in a substantial worldwide increase in AF-related stroke, particularly in elderly patients and this is creating an increasingly serious healthcare burden. Guidelines recommend the use of AF-related stroke prophylaxis but adherence to these remains poor. Studies conducted in the 1990s showed that warfarin reduced the risk of AF-related stroke by an overall 64% compared with placebo. Subsequently, prophylactic treatment was further improved with the development of non-vitamin K antagonist oral anticoagulants (NOACs). More recently, a meta-analysis of four large clinical trials on NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) showed there was a relative risk reduction of 0.81 (p<0.0001) favouring NOAC treatment over warfarin for stroke or systemic embolic events in patients with AF. The largest trial of NOACs in AF-related stroke, to date, was the ENGAGE AF-TIMI 48 study (n=21,105) which showed that edoxaban was non-inferior to warfarin for ischaemic stroke reduction but significantly reduced bleeding and cardiovascular mortality. A recent subgroup analysis of this study showed that with edoxaban the incidences of intracranial haemorrhage (ICH) subtypes (all ICH, fatal ICH, fatal, subdural and epidural bleed) were significantly lower with 60 mg of edoxaban (p=0.013–<0.001). Edoxaban was also shown to be an effective option in patients with prior stroke. In addition, edoxaban was shown to reduce deaths due to fatal bleeds compared with warfarin. The results of current studies, especially the ENGAGE AF-TIMI 48 subgroup analysis therefore, show that the benefits of anticoagulation therapy in patients with AF substantially outweigh the risks.

Greater Severity of Neurological Defects in Women Admitted With Atrial Fibrillation-Related Stroke

The magnitude of the CHA2DS2-VASc score is associated with not only stroke incidence but also long-term outcomes. The association between sex and initial stroke severity in AF-related cardioembolic stroke patients has not been clarified. The present study aimed to elucidate the risk factors for initial stroke severity among patients with cardioembolic stroke enrolled in a multicenter registry. We selected 12,701 patients (age, 77±10 years; 5,653 women) with AF-related cardioembolic stroke from the Japan Standard Stroke Registry Study between January 2000 and July 2013. Indicators of National Institutes of Health Stroke Scale (NIHSS) scores at admission were identified using a multiple linear regression. Increased NIHSS scores positively correlated with CHA2DS2-VASc score (ρ=0.197; P<0.001). The initial neurological deficits were more severe in women than in men (NIHSS scores, median [interquartile range] 14 [5-22] vs. 8 [3-18]; P<0.001). Multiple regression analysis revealed that higher age (standardized partial regression coefficient [β] 0.162; P<0.001), female sex (β 0.120; P<0.001), diabetes mellitus (β 0.020; P=0.019), dyslipidemia (β -0.076; P<0.001), congestive heart failure (β 0.039; P<0.001), vascular disease (β 0.030; P=0.001), prior stroke/TIA (β 0.085; P<0.001) and prior anticoagulant use (β -0.020; P=0.028) were associated with the NIHSS score at admission. Female sex was independently associated with the initial neurological severity among AF-related cardioembolic stroke patients.

Atrial fibrillation-related strokes: a prevention priority

British Journal of Neuroscience NursingVol. 11, No. 6 Conference ReportAtrial fibrillation-related strokes: a prevention priorityAlex WieronieyAlex WieronieySearch for more papers by this authorAlex WieronieyPublished Online:26 Dec 2015https://doi.org/10.12968/bjnn.2015.11.6.296AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Institute for Health and Care Excellence (2014) Atrial fibrillation: management. www.nice.org.uk/guidance/cg180 (accessed 12 December 2015) Google ScholarNHS Improvement (2013) Guidance on Risk Assessment and Stroke Prevention for Atrial Fibrillation (GRASP-AF). http://tinyurl.com/pnvvwj4 (accessed 12 December 2015) Google ScholarStroke Association (2015) AF: How can we do better? http://tinyurl.com/nmhklka (accessed 12 December 2015) Google Scholar FiguresReferencesRelatedDetails 2 December 2015Volume 11Issue 6ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 26 December 2015 Published in print 2 December 2015 Information© MA Healthcare LimitedPDF download

Abstract 19468: Timing of Atrial Fibrillaiton-related Stroke and the Risk of All-cause Mortality

Introduction: Strokes that occur after the onset of atrial fibrillation (AF) have a worse prognosis than strokes that do not occur in the setting of AF. Recent studies suggest that strokes that occur within several months prior to an AF diagnosis may be related to underlying, silent AF. Limited studies have evaluated survival differences between AF-related strokes that occur prior versus after AF diagnosis. Objective: We evaluated differences in the risk of all-cause death between patients that develop stroke in the 6 months before compared to any time after the diagnosis of AF. Methods: We utilized the University of Pennsylvania AF Free study to create an inception cohort of patients with incident stroke and AF. We assessed ECGs, clinical records, and administrative data within the health system over a 5 year period to identify individuals that had a first diagnosis of stroke or AF. Cox proportional hazards models evaluated associations between stroke subtypes and death. Results: We identified 3,616 individuals that developed stroke (323 had stroke after AF diagnosis, 292 patients had stroke within 6 months preceding AF diagnosis, and 2795 patients had stroke without an AF diagnosis). Of these patients, there were 319 all-cause mortality events over a median 4.6 [3.8, 5.5] years follow-up. The overall mortality rate was highest in patients that had a stroke within 6 months prior to AF (Table 1) and was almost 2-fold higher than those that had a stroke after an AF diagnosis (p&lt;0.001). After multivariable adjustment, patients with an AF-related stroke that occurred within 6-months prior to the diagnosis of AF had a significantly higher risk of death than those with stroke that occurred after an AF diagnosis or those with stroke but no AF (Table 1). Conclusions: Stroke that occurs prior to the diagnosis of AF was associated with a significantly higher risk of all-cause death. This increased mortality risk is not explained by the presence of other comorbid conditions.

Recent time trends in incidence, outcome and premorbid treatment of atrial fibrillation-related stroke and other embolic vascular events: a population-based study

BackgroundPrevalence of atrial fibrillation (AF) is increasing, due partly to the ageing population. The Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Trial, published in 2007, provided strong evidence of...

Rates and Determinants of 5-Year Outcomes After Atrial Fibrillation-Related Stroke: A Population Study.

Demographic trends in atrial fibrillation (AF) incidence may yield a substantial rise in the societal burden of AF-related stroke (AF-stroke). Accurate population-wide outcome data are essential to inform health service planning to improve AF-stroke prevention, and provision of rehabilitation, nursing home, and community supports for AF-stroke survivors. We investigated rates and determinants of 5-year fatality, stroke recurrence, functional outcomes, and prescribing of secondary prevention medications in AF-stroke in the North Dublin Population Stroke Study. Ascertainment included hot and cold pursuit using multiple overlapping sources. Survival analysis was performed using lifetables and Kaplan-Meier survival curves, and Cox proportional hazard modeling was performed to identify predictors of death and recurrent stroke. Five hundred sixty-eight patients with new stroke were identified, including 177 (31.2%) AF-stroke. At 5 years, 39.2% (confidence interval, 31.5-46.8) of ischemic AF-stroke patients were alive. Congestive heart failure, hypertension, age <65, 65-74 years, and ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack or thromboembolism, vascular disease and female sex (CHA2DS2-VASc) score (hazard ratio [HR], 1.34; P<0.001), CHADS2 score (HR 1.42, P=0.004), National Institute of Health Stroke Scale (HR, 1.09; P<0.0001), and subtherapeutic international normalized ratio (<2.0) at stroke onset (HR, 3.29; P=0.003) were independently associated with 5-year fatality, whereas warfarin (HR, 0.40; P=0.001) and statin use after index stroke (HR, 0.52; P=0.005) were associated with improved survival. The 5-year recurrence rate after ischemic AF-stroke was 21.5% (confidence interval, 14.5-31.3). Trends toward greater risk of recurrence were observed for persistent AF (HR, 3.09; P=0.07) and CHA2DS2-VASc score (HR, 1.34; P=0.07). Nursing home care was needed for 25.9% of patients. AF-stroke is associated with considerable long-term morbidity, fatality, stroke recurrence, and nursing home requirement. Adequately resourced national AF strategies to improve AF detection and prevention are needed.

The history of hypertension among the cha2ds2-vasc risk factors is associated with worse stroke severity in non-valvular atrial fibrillation-related stroke

The history of hypertension among the cha2ds2-vasc risk factors is associated with worse stroke severity in non-valvular atrial fibrillation-related stroke

Exclusion of the left atrial appendage with the TigerPaw II system: a word of caution.

Exclusion of the left atrial appendage (LAA) may significantly reduce the incidence of stroke associated with atrial fibrillation (AF), since this is the main thrombus source. LAA closure is becoming a therapeutic target for preventing AF-related stroke, attracting much interest in recent years. Different devices are available to provide LAA exclusion during cardiac surgery. We describe herein our experience with the recently introduced TigerPaw II system for LAA exclusion, and report a high prevalence of device malfunction. Design improvements may address these issues and increase safety for new technological devices designed for surgical LAA closure.

Stroke prevention following modified endoscopic ablation and appendectomy for atrial fibrillation.

We reported the results of stroke prevention following modified endoscopic procedure for atrial fibrillation. 82 patients underwent modified endoscopic procedure for atrial fibrillation (AF), in whom 47 had paroxysmal, 28 had persistent, and 7 had long-standing atrial fibrillation. CHA2DS2VASC median score was 3 (range from 0 to 8). The procedure was performed on the beating heart, through 3 ports on the left chest wall. Pulmonary vein isolation and ablation of the left atrium were achieved by bipolar radiofrequency ablation. Left atrial appendage (LAA) was excluded by stapler. Brain CT, cardiac CT and 24-h Holter monitoring were performed following the procedure. The procedure was successfully completed for all patients. The mean duration was 122±40.1min. LAA was excluded after appendectomy and checked by intraoperative transesophageal echocardiography. The mean follow-up duration was 24.3±3.5months. No patients showed signs and symptoms of transient ischemic attack or stroke. No new positive findings were demonstrated by recurring brain CT scan performed after the procedure. Cardiac CT confirmed the absence of LAA and thrombosis in the left atrium. 87.8% (72/82) of all patients were in sinus rhythm. Our results demonstrate that the modified endoscopic procedure is a safe, effective, and appropriate treatment for AF, which restores sinus rhythm and may be associated with the prevention of AF-related stroke.

Decision-making about the use of non-vitamin K oral anticoagulant therapies for patients with atrial fibrillation.

Until recently, vitamin K antagonists, warfarin being the most commonly used agent in the United States, have been the only oral anticoagulant therapies available to prevent stroke in patients with atrial fibrillation (AF). In the last 5 years four new, non-vitamin K oral anticoagulants, the so-called NOACs or novel oral anticoagulants, have come to market and been approved by the Federal Drug Administration. Despite comparable if not superior efficacy in preventing AF-related stroke, and generally lower risks of major hemorrhage, particularly intracranial bleeding, the uptake of these agents has been slow. A number of barriers stand in the way of the more widespread use of these novel agents. Chief among them is concern about the lack of antidotes or reversal agents. Other concerns include the need for strict medication adherence, since missing even a single dose can lead to a non-anticoagulated state; out-of-pocket costs for patients; the lack of easily available laboratory tests to quantitatively assess the level of anticoagulant activity when these agents are being used; contraindications to use in patients with severe chronic kidney disease; and black-box warnings about the increased risk of thromboembolic events if these agents are discontinued prematurely. Fortunately, a number of reversal agents are in the pipeline. Three reversal agents, idarucizumab, andexanet alfa, and aripazine, have already progressed to human studies and show great promise as either antidotes for specific drugs or as universal reversal agents. The availability of these reversal agents will likely increase the clinical use of the non-vitamin K oral anticoagulants. In light of the many complex and nuanced issues surrounding the choice of an optimal anticoagulant for any AF patient, a patient-centered/shared decision-making approach will be useful.

Extracranial Systemic Embolic Events in Patients With Nonvalvular Atrial Fibrillation: Incidence, Risk Factors, and Outcomes.

Nonvalvular atrial fibrillation is a major cause of thromboembolic events. In comparison with atrial fibrillation-related stroke, extracranial systemic embolic events (SEEs) remain poorly defined. All suspected SEEs reported among 37 973 participants of 4 large contemporary randomized clinical trials of anticoagulation in atrial fibrillation were independently readjudicated for clinical and objective evidence of sudden loss of perfusion of a limb or organ. Over 91 746 patient-years of follow-up, 221 SEEs occurred in 219 subjects. The SEE incidence was 0.24 of 100 and stroke incidence was 1.92 of 100 patient-years. In comparison with patients with stroke, those with SEE were more often female (56% versus 47%; P=0.01) and had comparable mean age (73.1±8.5 versus 73.5±8.8 years; P=0.57) and mean CHADS2 scores (2.4±1.3 versus 2.5±1.2; P=0.33). SEEs more frequently involved the lower extremity (58%) than visceral-mesenteric (31%) or upper extremity (10%). SEE-related care involved clinic assessment alone in 5%, 30% were hospitalized without procedures, 60% underwent endovascular or surgical intervention, and 5% underwent amputation. Within 30 days, 54% of patients recovered fully, 20% survived with deficits, and 25% died. Thirty-day mortality was greater after visceral-mesenteric than lower- or upper-extremity SEE (55%, 17%, and 9%, respectively, P≤0.0001). The relative risk of death throughout follow-up was 4.33 (95% confidence interval, 3.29-5.70) after SEE versus 6.79 (95% confidence interval, 6.22-7.41) after stroke in comparison with patients without either event. SEE constituted 11.5% of clinically recognized thromboembolic events in patients with atrial fibrillation and was associated with high morbidity and mortality. SEE mortality was comparable to that of ischemic stroke and varied by anatomic site.

The Left Atrial Appendage in Health and Disease

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmiaand results in significant morbidity and mortality. The left atrial appendage (LAA), a small embryonic remnant of the left atrium (LA), has been shown to play a key role in the pathophysiology of AF-related stroke and thromboembolism. As a consequence the LAA, in spite of its meagre size, has been described as ‘our most lethal human attachment’. Despite being a recognised harbinger of disease, the LAA has also been shown to play an important role in health. This review seeks to address our current understanding of this vital structure in both health and disease states.

Underutilisation of Guideline-based Therapy Primary Prevention among Patients Presenting with AF-related Ischaemic Stroke

Underutilisation of Guideline-based Therapy Primary Prevention among Patients Presenting with AF-related Ischaemic Stroke

Oral Anticoagulant Therapy in Atrial Fibrillation Patients at High Stroke and Bleeding Risk

Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. Most AF patients have a positive net clinical benefit from OAC, excluding those with AF and no conventional stroke risk factors. Balancing the risks of stroke and bleeding is necessary for optimal use of OAC in clinical practice, and modifiable bleeding risk factors must be addressed. Concerns remain over ‘non-changeable’ bleeding risk factors such as older age, significant renal or hepatic impairment, prior stroke(s) or prior bleeding event(s) and active malignancies. Such AF patients are often termed ‘special’ AF populations, due to their ‘special’ risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients.In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these ‘special’ AF populations.

Metabolic syndrome, atrial fibrillation, and stroke: Tackling an emerging epidemic

The prevalence of atrial fibrillation (AF) and AF-related stroke is set to increase dramatically in coming decades, with developing regions such as Latin America experiencing the greatest impact. These trends are primarily driven by aging populations and by the increasing prevalence of the metabolic syndrome. The metabolic syndrome describes an association between diabetes, hypertension, obesity, and dyslipidemia and an increased risk of cardiovascular disease. It is in large part the result of unbalanced diet and sedentary lifestyle. These essentially modifiable risk factors are becoming more prevalent with the widespread adoption of so-called Western lifestyles. This review examines the physiology underlying the link between the metabolic syndrome and AF. Next, it highlights the importance of addressing lifestyle-related risk factors to mitigate the trend toward increasing AF prevalence. It then goes on to discuss the importance of stroke prevention therapy in patients with established AF, focusing on the relative merits of various available options for anticoagulation. Given the recent availability of comprehensive data on the 4 currently available non-vitamin K antagonist oral anticoagulant drugs, this review concludes by discussing the relative merits of specific agents in individual patient groups.

Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study.

Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited. In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]). AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.

Stroke prevention in atrial fibrillation: findings from Tuscan FADOI Stroke Registry

Despite vitamin K antagonists (VKAs) are considered the first choice treatment for stroke prevention in atrial fibrillation (AF), literature shows their underuse in this context. Since data about VKAs use prior and after acute stroke lack, the aim of this study was to focus on management of anticoagulation with VKAs in this context. Data were retrieved from Tuscan FADOI Stroke Registry, an online data bank aimed to report on characteristics of stroke patients consecutively admitted in Internal Medicine wards in 2010 and 2011. In this period 819 patients with mean age 76.5±12.3 years were enrolled. Data on etiology were available for 715 of them (88.1%), 87% being ischemic and 13% hemorrhagic strokes. AF was present in 238 patients (33%), 165 (69.3%) having a known AF before hospitalization, whereas 73 patients (31.7%) received a new diagnosis of AF. A percentage of 89% of strokes in patients with known AF were ischemic and 11% hemorrhagic. A percentage of 86.7% of patients with known AF had a CHADS&lt;sub&gt;2&lt;/sub&gt; ≥2, but only 28.3% were on VKAs before hospitalization. A percentage of 78.8% of patients treated with VKAs before stroke had an international normalized ratio (INR) ≤2.0; 68.7% of patients with VKAs-related hemorrhagic strokes had INR ≤3.0. Combined endpoint mortality or severe disability in patients with ischemic stroke associated with AF was present in 47%, while it was present in 19.30% and 19.20% of atherothrombotic and lacunar strokes, respectively. At hospital discharge, VKAs were prescribed in 25.9% of AF related ischemic stroke patients. AF related strokes are burdened by severe outcome but VKAs are dramatically underused in patients with AF, even in higher risk patients. Efforts to improve anticoagulation in this stroke subtype are warranted.

Abstract 100: Influence of Race on Presentation, Treatment, and Outcome Among Patients With Atrial Fibrillation-related Ischemic Stroke

Background: Blacks have been underrepresented (&lt;2% of 71,683) in recent atrial fibrillation (AF) trials of novel anticoagulants vs. warfarin. Blacks with AF have also been underrepresented in stroke cohort studies from which the stroke risk prediction rules are derived. Objective: We examined whether there exist racial differences in presentation, treatment, and outcome among patients with AF-related ischemic stroke (IS). Methods: Consecutive IS were identified from 2006-2010 at 3 U.S. sites. All events were evaluated by CT or MRI, and assigned a discharge modified Rankin score (mRS). AF was confirmed by ECG. Baseline medications and clinical characteristics were abstracted from the medical record. Race was determined by self-report. Findings: We identified 1,030 AF-related IS; 96% (n=985) had race reported as White (n=764, 74%) or Black (n=221, 21%). Compared to Whites, Blacks were younger, had a higher burden of risk factors, had higher prevalence of paroxysmal or new onset AF, and more often presented outside the t-PA window. Among patients with known AF, 40% Whites and 39% Blacks were taking warfarin on admission. INR on admission was not different by race (mean 1.4, SD =0.7; p=0.64). These strokes resulted in severe neurological deficit (mRS &gt;3) in a majority of Blacks and Whites (70% vs. 64%; p=0.09). Conclusion: Blacks with AF who suffer IS are younger, have a higher burden of risk factors, and more often present with paroxysmal or new onset AF. IS in the setting of AF was associated with significant mortality and morbidity in both Blacks and Whites.