Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation

Shadi Yaghi, Ava L. Liberman, Nils Henninger, Brian Mac Grory, Amre Nouh, Erica Scher, James Giles, Angela Liu, Muhammad Nagy, Ashutosh Kaushal, Idrees Azher, Hiba Fakhri, Kiersten Brown Espaillat, Syed Daniyal Asad, Hemanth Pasupuleti, Heather Martin, Jose Tan, Manivannan Veerasamy, Charles Esenwa, Natalie ChengKhadean Moncrieffe, Iman Moeini-Naghani, Mithilesh Siddu, Tushar Trivedi, Koto Ishida, Jennifer Frontera, Aaron Lord, Karen Furie, Salah Keyrouz, Adam de Havenon, Eva Mistry, Christopher R. Leon Guerrero, Muhib Khan

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background and purpose: Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. Methods: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status. Results: Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10–2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06–3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke. Conclusion: Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.

Original languageEnglish (US)
Article number104888
JournalJournal of Stroke and Cerebrovascular Diseases
Issue number7
StatePublished - Jul 2020


  • Anticoagulation
  • Atrial fibrillation
  • Predictors
  • Recurrence
  • Stroke

ASJC Scopus subject areas

  • Surgery
  • Rehabilitation
  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine


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