Background: Oral anticoagulation (OAC) is the only treatment that has shown a significant benefit to reduce the risk of recurrence in patients with ischemic stroke and nonvalvular atrial fibrillation (NVAF). However, OAC is still underused, even at discharge from neurological centers. The objective of this study was to identify the reasons underlying the prescription of OAC at discharge after an ischemic stroke in patients with NVAF. Methods: We investigated the reasons why ischemic stroke patients with NVAF were not treated with OAC at discharge from 40 centers located in 5 European countries (Austria, Belgium, France, Italy, and Portugal). Results: Of 320 ischemic stroke survivors at discharge, 186 (58.1%) received OAC, while 260 (81.3%) patients were theoretically eligible according to guidelines and the absence of contraindications. There were significant differences between countries and the logistic regression analysis found being already under OAC before stroke, having no leukoaraiosis, having no potential contraindication, being younger than 75 years, being married and suffering from angina pectoris as independent predictors of being discharged under OAC. Conclusion: This study suggests that besides patient-related factors, the prescription of OAC is also significantly influenced by the social environment and national practices.

Keywords:
Stroke, Atrial fibrillation, Secondary prevention, Oral anticoagulation, Antiplatelet drugs
1.
European Atrial Fibrillation Trial Study Group: Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993;342:1255–1262.
2.
Stroke Prevention in Atrial Fibrillation Investigators: Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: the Stroke Prevention in Atrial Fibrillation III randomized clinical trial. Lancet 1996;348:633–638.
3.
Hart RG, Pearce LA, Koudstaal PJ: Transient ischemic attacks in patients with atrial fibrillation. Implications for secondary prevention: the European Atrial Fibrillation Trial and Stroke Prevention in Atrial Fibrillation III trial. Stroke 2004;35:948–951.
4.
Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ: Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:429S–456S.
5.
Leys D, Kwiecinski H, Bogousslavsky J, Bath P, Brainin M, Diener HC, Kaste M, Sivenius J, Hennerici MG, Hacke W; EUSI Executive Committee; EUSI Writing Committee: Prevention. European Stroke Initiative. Cerebrovasc Dis 2004;17(suppl 2):15–29.
6.
Evans A, Kalra L: Are the results of randomized controlled trials on anticoagulation in patients with atrial fibrillation generalizable to clinical practice? Arch Intern Med 2001;161:1443–1447.
7.
McCormick D, Gurwitz JH, Goldberg RJ, Becker R, Tate JP, Elwell A, Radford MJ: Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med 2001;161:2458–2463.
8.
Scott PA, Pancioli AM, Davis LA, Frederiksen SM, Eckman J: Prevalence of atrial fibrillation and antithrombotic prophylaxis in emergency department patients. Stroke 2002;33:2664–2669.
9.
Go AS, Hylek EM, Borowsky LH, Philips KA, Selby JV, Singer DE: Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med 1999;131:927–934.
10.
Deplanque D, Corea F, Arquizan C, Parnetti L, Mas JL, Gallai V, Leys D; SAFE I Study Investigators: Stroke and atrial fibrillation: is stroke prevention treatment appropriate beforehand? Heart 1999;82:563–569.
11.
Deplanque D, Leys D, Parnetti L, Schmidt R, Ferro J, De Reuck J, Mas JL, Gallai V; SAFE II Investigators: Stroke prevention and atrial fibrillation: reasons leading to an inappropriate management. Main results of the SAFE II study. Br J Clin Pharmacol 2004;57:798–806.
12.
Albers GW, Bittar N, Young L, Hattemer CR, Gandhi AJ, Kemp SM, Hall EA, Morton DJ, Yim J, Vlasses PH: Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals. Neurology 1997;48:1598–1604.
13.
Brass LM, Krumholz HM, Scinto JD, Mathur D, Radford M: Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med 1998;158:2093–2100.
14.
Evans A, Perez I, Yu G, Kalra L: Secondary stroke prevention in atrial fibrillation. Lessons from clinical practice. Stroke 2000;32:2106–2111.
15.
Evans A, Perez I, Yu G, Kalra L: Should stroke subtype influence anticoagulation decisions to prevent recurrence in stroke patients with atrial fibrillation? Stroke 2001;32:2828–2832.
16.
Glader EL, Stegmayr B, Norrving B, Terent A, Hulter-Asberg K, Wester PO, Asplund K; Riks-Stroke Collaboration: Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: a Swedish national perspective. J Intern Med 2004;255:22–32.
17.
Tentschert S, Parigger S, Dorda V, Bittner K, Unterbuchschachner D, Greisenegger S, Wimmer R, Brucke T, Lang W, Lalouschek W; Vienna Stroke Study Group: Recurrent vascular events in patients with ischemic stroke/TIA and atrial fibrillation in relation to secondary prevention at hospital discharge. Wien Klin Wochenschr 2004;116:834–838.
18.
Mead GE, Lewis SC, Wardlaw JM, Dennis MS, Warlow CP: How well does the Oxfordshire community stroke project classification predict the site and size of the infarct on brain imaging? J Neurol Neurosurg Psychiatry 2000;68:558–562.
19.
Mounier-Vehier F, Leys D, Rondepierre P, Godefroy O, Pruvo JP: Silent infarcts in patients with ischemic stroke are related to age and size of the left atrium. Stroke 1993;24:1347–1351.
20.
Sulter G, Steen C, De Keyser J: Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:1538–1541.
21.
Folstein MF, Folstein SE, McHugh PR: ‘Mini Mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.
22.
Bendel RB, Afifi AA: Comparison of stopping rules in forward regression. J Am Stat Assoc 1977;72:46–53.
23.
Giroud M, Milan C, Beuriat P, Gras P, Essayagh E, Arveux P, Dumas R: Incidence and survival rates during a two-year period of intracerebral and subarachnoid haemorrhages, cortical infarcts, lacunes and transient ischemic attacks: the stroke registry of Dijon, 1985–1989. Int J Epidemiol 1991;20:892–899.
24.
Palareti G, Leali N, Coccheri S, Poggi M, Manotti C, D’Angelo A, Pengo V, Erba N, Moia M, Ciavarella N, Devoto G, Berrettini M, Musolesi S: Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Italian Study on Complications of Oral Anticoagulant Therapy. Lancet 1996;348:423–428.
25.
Fang MC, Chang Y, Hylek EM, Rosand J, Greenberg SM, Go AS, Singer DE: Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med 2004;141:745–752.
26.
Connolly S; for the Atrial Fibrillation Investigators: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994;343:1509.
27.
The European Atrial Fibrillation Trial study Group: Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral infarction. N Engl J Med 1995;333:5–10.
28.
Penado S, Cano M, Acha O, Hernandez JL, Riancho JA: Atrial fibrillation as a risk factor for stroke recurrence. Am J Med 2003;114:206–210.
29.
Gorter JW: Major bleeding during anticoagulation after cerebral ischemia. Patterns and risk factors. Stroke Prevention In Reversible Ischemia Trial (SPIRIT). European Atrial Fibrillation Trial (EAFT) study groups. Neurology 1999;53:1319–1327.
30.
Smith EE, Rosand J, Knudsen KA, Hylek EM, Greenberg SM: Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke. Neurology 2002;59:193–197.
31.
Lefebvre C, Deplanque D, Touzé E, Hénon H, Parnetti L, Pasquier F, Gallai V, Leys D; on behalf of the SAFE II investigators: Prestroke dementia in patients with atrial fibrillation: frequency and associated factors. J Neurol 2005;252:1504–1509.
32.
The Atrial Fibrillation Investigators: The efficacy of aspirin in patients with atrial fibrillation. Analysis of pooled data from 3 randomized trials. Arch Intern Med 1997;157:1237–1240.
33.
EUROASPIRE I and II Group: Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001;357:995–1001.
34.
Landi F, Cesari M, Onder G, Zamboni V, Lattanzio F, Russo A, Barillaro C, Bernanei R; SILVERNET-HC Study Group: Antithrombotic drugs in secondary stroke prevention among a community dwelling older population. J Neurol Neurosurg Psychiatry 2003;74:1100–1104.
35.
Monesi L, Avanzini F, Barlera S, Caimi V, Lauri D, Longoni P, Roccatagliata D, Tombesi M, Tognoni G, Roncaglioni MC: Appropriate use of antiplatelets: is prescription in daily practice influenced by the global cardiovascular risk? Eur J Clin Pharmacol 2005;61:595–601.
36.
Poli D, Antonucci E, Lombardi A, Cecchi E, Corsini I, Gensini GF, Abbate R, Prisco D: Low incidence of hemorrhagic complications of oral anticoagulant therapy in patients with atrial fibrillation in the daily practice of an anticoagulation clinic. Ital Heart J 2003;4:44–47.
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2006
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