Secondary Prevention in Patients with Non Valvular Atrial Fibrillation and Previous Stroke. Is It Possible to Have an Appropriate INR Control?

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Topic: 5. Secondary Prevention of Cardiovascular Disease.



Coumadin therapy has been the best oral anticoagulation strategy available since several decades and is considered obligatory in some countries as the first strategy to be attempted because of economical reasons/arguments.


To evaluate if patients already identified at highest-risk of stroke receive appropriate anticoagulation with dicumarinics and this strategy can be subsequently recommended in the actual days.


We analyzed the quality of anticoagulation with coumadin in our area and its clinical consequences. For that purpose, we selected a very high-risk population (previously diagnosed of a possible cardioembolic stroke and concomitant Atrial Fibrillation (AF)) in whom is mandatory to have an excellent anticoagulant level. All consecutive INR measurement were considered for all patients as well as their outcomes.


A total of 4416 INR level determinations from 125 consecutive patients (age: 76.6 + 9 years, females: 62. %, CHA2DS2-VASC: 5.2 + 1.7) were included in the analysis during a follow-up period of 23±20 months. The mean number of INR determinations per patient was 34±25. It was found that 1946 INR determinations (44 %) showed an inappropriate level (<2 or >3). Thus, a mean of 14±11 determinations/person were out of the therapeutic range and overall patients were during 7.9±8 months at risk of thromboembolic or bleeding events in relationship to INR out of therapeutic range.

Furthermore, during the follow-up period, cardiovascular events (any ischemic or hemorrhagic event) occurred in 66 patients (53 %) with INR at the time of the event being inappropriate in 66 % of the cases.


Even in a very high risk population with AF treated with coumadin because of secondary stroke prevention, the INR control is poor and is related to cardiovascular new events.