Factors influencing physicians' reported use of anticoagulation therapy in nonvalvular atrial fibrillation: a cross-sectional survey. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Previous Intracerebral Hemorrhage. Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Asian Patients With Atrial Fibrillation Advanced Age, Anticoagulation Intensity, and Risk for Intracranial Hemorrhage among Patients Taking Warfarin for Atrial Fibrillation Effects of Aspirin and Clopidogrel versus Oral Anticoagulation on Platelet Function and on Coagulation in Patients with Nonvalvular Atrial Fibrillation (CLAFIB) Effect of Age on Stroke Prevention Therapy in Patients With Atrial Fibrillation: The Atrial Fibrillation Investigators A randomized trial to assess the impact of an antithrombotic decision aid in patients with nonvalvular atrial fibrillation: the DAAFI trial protocol [ISRCTN14429643] Low-dose aspirin for prevention of stroke in low-risk patients with atrial fibrillation: Japan Atrial Fibrillation Stroke Trial. Values and Preferences of Physicians and Patients With Nonvalvular Atrial Fibrillation Who Receive Oral Anticoagulation Therapy for Stroke Prevention. Variation in Restarting Antithrombotic Drugs at Hospital Discharge After Intracerebral Hemorrhage Long-Term Outcome after Anticoagulation-Associated Intracerebral Haemorrhage with or without Restarting Antithrombotic Therapy Outpatient management of oral anticoagulation therapy in patients with nonvalvular atrial fibrillation.
BACKGROUND Some elderly patients with nonvalvular atrial fibrillation ( NVAF ) who might benefit from warfarin therapy do not receive it . OBJECTIVE The goal of this cross-sectional study was to identify physicians ' attitudes and beliefs that are associated with their reported use of warfarin in case scenarios . METHODS A self-administered survey was mailed to a cross-section of general internists r and omly selected from a national pool of physicians in the American Medical Association Masterfile . Fourteen clinical vignettes were used , incorporating various comorbid conditions and risk factors for either major bleeding episode or embolic cerebrovascular accident ( CVA ) . The outcome measure was the number of case vignettes for which warfarin was recommended . RESULTS A total of 142 completed surveys ( 33 % of 426 eligible respondents ; 109 men , and 32 women [ 1 respondent did not provide gender ] ; mean [ SD ] age , 45 [ 10 ] years ) were received . The median number of case vignettes for which warfarin was recommended was 10 ( interquartile range , 8 - 12 ) . We found no relationship between the perceived benefits of warfarin and its use in the case vignettes . However , the perceived risk for warfarin associated hemorrhage was strongly associated with reported warfarin use ( P < 0.001 ) . The physicians in our sample provided estimates of the annual rate of warfarin-associated intracerebral hemorrhage that were > 10-fold higher than literature -based estimates , and physicians providing higher risk estimates tended to use warfarin less often . On multivariate logistic regression , physicians who recommended warfarin use in more vignettes were less likely to report anticipated regret of committing an error of omission ( ischemic CVA in an untreated NVAF patient ) ( P < 0.001 ) or a loss-aversive risk preference ( P = 0.027 ) , and had a lower perceived annual risk for hemorrhage with warfarin ( P < 0.001 ) . Physician age , sex , primary mechanism of reimbursement , academic appointment , and the NVAF patient volume all were unrelated to warfarin use . CONCLUSIONS Although the decision to use warfarin in NVAF was not driven by the perceived benefit , the perceived risks strongly affected warfarin use . Response bias is a potential limitation , but our data strongly suggest that physicians ' attitudes toward anticipated regret and risk aversion can impact on their treatment recommendations BACKGROUND Warfarin sodium is highly effective for prevention of embolic stroke , particularly in nonvalvular atrial fibrillation , but its expected benefit can be offset by risk of intracerebral hemorrhage ( ICH ) . We studied the determinants of ICH outcome to quantify the independent effect of warfarin . METHODS Consecutive patients with supratentorial ICH treated in a tertiary care hospital with a neurointensive care unit were prospect ively identified during a 7-year period , and data on hemorrhage location , clinical characteristics , and warfarin use were collected . Independent predictors of 3-month mortality were determined using multiple logistic regression analysis . RESULTS Of 435 consecutive patients aged 55 years or older , 102 ( 23.4 % ) were taking warfarin at the time of ICH .  Three-month mortality was 25.8 % for those not taking warfarin and 52.0 % for those taking warfarin . Independent predictors of death were warfarin use ( odds ratio [ OR ] , 2.2 ; 95 % confidence interval [ CI ] , 1.3 - 3.8 ) , age 70 years or older ( OR , 2.4 ; 95 % CI , 1.4 - 4.0 ) , and presence of diabetes mellitus ( OR , 1.8 ; 95 % CI , 1.0 - 3.3 ) . Although 68.0 % of all warfarin-related hemorrhages occurred at an international normalized ratio ( INR ) of 3.0 or less , increasing degrees of anticoagulation were strongly associated with increasing risk of death compared with no warfarin use . CONCLUSIONS Patients taking warfarin  had a doubling in the rate of intracerebral hemorrhage mortality in a dose-dependent manner . The data suggest that careful control of the INR , already known to limit the risk of warfarin-related ICH , may also limit its severity IMPORTANCE Although use of oral anticoagulants ( OACs ) is increasing , there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage ( ICH ) . OBJECTIVE To assess the association of anticoagulation reversal and blood pressure ( BP ) with  hematoma enlargement and the effects of OAC resumption . DESIGN , SETTING , AND PARTICIPANTS Retrospective cohort study at 19 German tertiary care centers ( 2006 - 2012 ) including 1176 individuals for analysis of long-term functional outcome , 853 for analysis of hematoma enlargement , and 719 for analysis of OAC resumption . EXPOSURES Reversal of anticoagulation during acute phase , systolic BP at 4 hours , and reinitiation of OAC for long-term treatment . MAIN OUTCOMES AND MEASURES Frequency of hematoma enlargement in relation to international normalized ratio ( INR ) and BP . Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption . Factors associated with favorable ( modified Rankin Scale score , 0 - 3 ) vs unfavorable functional outcome . RESULTS Hemorrhage enlargement occurred in 307 of 853 patients ( 36.0 % ) . Reduced rates of hematoma enlargement were associated with reversal of INR levels < 1.3 within 4 hours after admission ( 43/217 [ 19.8 % ] ) vs INR of ≥1.3 ( 264/636 [ 41.5 % ] ; P < .001 ) and systolic BP < 160 mm Hg at 4 hours ( 167/504 [ 33.1 % ] ) vs ≥160 mm Hg ( 98/187 [ 52.4 % ] ; P < .001 ) . The combination of INR reversal < 1.3 within 4 hours and systolic BP of < 160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement ( 35/193 [ 18.1 % ] vs 220/498 [ 44.2 % ] not achieving these values ; OR , 0.28 ; 95 % CI , 0.19 - 0.42 ; P < .001 ) and lower rates of in-hospital mortality ( 26/193 [ 13.5 % ] vs 103/498 [ 20.7 % ] ; OR , 0.60 ; 95 % CI , 0.37 - 0.95 ; P = .03 ) . OAC was resumed in 172 of 719 survivors ( 23.9 % ) . OAC resumption showed fewer ischemic complications ( OAC : 9/172 [ 5.2 % ] vs no OAC : 82/547 [ 15.0 % ] ; P < .001 ) and not significantly different hemorrhagic complications ( OAC : 14/172 [ 8.1 % ] vs no OAC : 36/547 [ 6.6 % ] ; P = .48 ) . Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 ( 95 % CI , 0.125 - 0.534 ; P < .001 ) for long-term mortality . Functional long-term outcome was unfavorable in 786 of 1083 patients ( 72.6 % ) . CONCLUSIONS AND RELEVANCE Among patients with OAC-associated ICH , reversal of INR < 1.3 within 4 hours and systolic BP < 160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement , and resumption of OAC therapy was associated with lower risk of ischemic events . These findings require replication and assessment in prospect i ve studies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01829581 BACKGROUND Percutaneous left atrial appendage closure ( LAAC ) may be considered in patients with atrial fibrillation and contraindication for long-term anticoagulation . This study aim ed to assess the safety and efficacy of LAAC followed by single antiplatelet therapy in patients with atrial fibrillation and previous spontaneous intracerebral hemorrhage ( ICH ) . METHODS In this explorative , prospect i ve , single-center study , consecutive patients who underwent LAAC because of previous spontaneous ICH over a period of 4 years were analyzed . Risks of ischemic strokes and hemorrhagic complications were estimated using the CHA2DS2-VASc and HAS-BLED scores , respectively . Single antiplatelet therapy was given for at least 6 months post implantation . Clinical follow-up included cardiological evaluations at 1 , 3 , 6 , and 12 months , and neurological evaluations at 3 and 12 months . RESULTS A total of 46 patients  underwent LAAC with a mean follow-up of 12 ± 7 months . The observed annual rate of ischemic stroke was 4.35 % compared with an expected rate of 7.23 % according to the mean risk of the population based on CHA2DS2-VASc score , which translated into a 40 % risk reduction . The observed annual rate of major bleeding was 4.35 % compared with an expected rate of 8.05 % according to the mean risk of the population based on HAS-BLED score , which translated into a 46 % risk reduction . CONCLUSIONS LAAC followed by single antiplatelet therapy is feasible as an alternative to oral anticoagulation in high-risk patients with previous ICH , with an acceptable periprocedural risk . Longer follow-up in a larger number of patients will be needed to establish the effectiveness of LAAC relative to direct oral anticoagulants Background and Purpose — There are limited real-world data comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants ( NOACs ) and warfarin in Asians with nonvalvular atrial fibrillation . We aim ed to compare the effectiveness and safety between NOACs and warfarin users in the Korean atrial fibrillation population , with particular focus on high-risk patients . Methods — Using the Korean National Health Insurance Service data base , we analyzed the risk of ischemic stroke , intracranial hemorrhage ( ICH ) events , and all-cause death in  NOAC users ( n=11 611 total , n=5681 taking rivaroxaban , n=3741 taking dabigatran , and n=2189 taking apixaban ) compared with propensity score-matched warfarin users ( n=23 222 ) among patients with high-risk atrial fibrillation ( CHA2DS2-VASc score ≥2 ) between 2014 and 2015 . Results — NOAC treatment was associated with similar risk of ischemic stroke and lower risk of ICH and all-cause mortality compared with warfarin . All 3 NOACs were associated with a similar risk of ischemic stroke and a lower risk of ICH compared with warfarin . Dabigatran and apixaban were associated with a lower risk of total mortality and the composite net clinical outcome ( ischemic stroke , ICH , and all-cause death ) compared with warfarin , whereas this was nonsignificant for rivaroxaban . Among previously oral anticoagulant – naive patients ( n=23 262 ) , dabigatran and apixaban were superior to warfarin  for ICH prevention , whereas rivaroxaban and warfarin were associated with similar risk of ICH . Conclusions — In real-world practice among a high-risk Asian atrial fibrillation population , all 3 NOACs demonstrated similar risk of ischemic stroke and lower risk of ICH  compared with warfarin . All-cause mortality was significantly lower only with dabigatran and apixaban Context The appropriate level of warfarin anticoagulation in elderly patients with atrial fibrillation has been debated because of an age-associated increase in intracerebral hemorrhage . Contribution Patients with atrial fibrillation and intracerebral hemorrhage who were receiving anticoagulation were matched with similar patients who did not develop intracerebral hemorrhage . Although intracerebral hemorrhage was associated with increasing age ( especially > 85 years ) and increasing international normalized ratios ( INRs ) ( especially > 3.5 ) , the incidence of intracerebral hemorrhage was not statistically different in patients with INRs less than 2.0 and those with INRs between 2.0 and 3.0 . This was true even among those older than 75 years of age . Implication s Risk for intracerebral hemorrhage is not diminished in elderly patients with atrial fibrillation when anticoagulation is maintained below an INR of 2.0 . The Editors Intracranial hemorrhage is the most dangerous complication of warfarin anticoagulant therapy because of its high short-term risk for death and severe neurologic deficit ( 1 - 5 ) . Warfarin is extremely effective in reducing the risk for ischemic stroke associated with atrial fibrillation ( 6 , 7 ) . However , fear of hemorrhage may prompt some physicians to avoid prescribing anticoagulation ( 8) , especially in elderly patients , who appear to have a higher risk for hemorrhage ( 8 - 13 ) . Prominent recent guidelines recommend using lower-intensity anticoagulation for the primary prevention of stroke in patients older than 75 years of age who have atrial fibrillation ( 14 ) and suggest a target international normalized ratio ( INR ) range of 1.6 to 2.5 , despite evidence that the risk for ischemic stroke increases sharply at INRs less than 2.0 ( 15 , 16 ) . Previous studies have not thoroughly addressed the relationship of age and anticoagulation intensity to the risk for intracranial hemorrhage among patients with atrial fibrillation ( 1 , 2 ) . A study of 121 patients with warfarin-associated intracranial hemorrhage used the now-out date d prothrombin time ratio as a measure of anticoagulation intensity and did not specifically address risk in patients with atrial fibrillation ( 1 ) . Earlier studies also included patients receiving anticoagulation for mechanical valves , whose risk-to-benefit ratio is different from that of patients with atrial fibrillation ( 1 , 2 , 17 ) . As the number of individuals with atrial fibrillation increases ( 18 - 21 ) and as a greater proportion of older adults receive anticoagulant therapy ( 22 ) , more precise data are needed about the association of age , INR , and risk for intracranial hemorrhage . Intracranial hemorrhage , although critically important , is an uncommon complication among patients with atrial fibrillation who are receiving anticoagulation . As a result , r and omized trials and cohort studies have difficulty accumulating enough hemorrhage events to powerfully assess risk factors . To address these limitations , we performed a large casecontrol study to evaluate the relationship of increasing age and INR to the risk for intracranial hemorrhage among patients with nonvalvular atrial fibrillation . Methods Case- Patients We performed a casecontrol study comparing 2 groups : 1 ) case- patients with nonvalvular atrial fibrillation who developed intracranial hemorrhage while taking warfarin and 2 ) controls who were receiving anticoagulation for nonvalvular atrial fibrillation but did not develop intracranial hemorrhage . We found potential case- patients using the Partners HealthCare System Research Patient Data Registry , which can identify patients with specific International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) diagnoses by search ing the Massachusetts General Hospital billing system . We search ed for patients 18 years of age or older who had diagnoses of atrial fibrillation ( ICD-9-CM code 427.31 ) and intracranial hemorrhage ( ICD-9-CM codes 430 , 431 , 432.0 , 432.1 , 432.9 ) at any time from October 1993 to June 2002 . By 1993 , nearly all prothrombin time ratios at the hospital were reported as INRs . We review ed medical records to confirm whether patients were eligible , that is , whether they had intracranial hemorrhage documented by computed tomography or magnetic resonance imaging and documentation of warfarin therapy for atrial fibrillation at the time of the event . We excluded patients who were not taking warfarin at the time of hemorrhage ; those who were receiving anticoagulation for rheumatic heart disease , mitral stenosis , or mechanical valve placement ; those whose event was an ischemic stroke with hemorrhagic conversion ; or those in whom clinical factors may have led to hemorrhage independent of warfarin therapy . These factors included underlying anatomic brain abnormalities ( such as tumors or aneurysms ) , antecedent major head trauma ( skull fracture , trauma with loss of consciousness , motor vehicle injury , or neurosurgical procedures ) , or platelet count less than 50 109 cells/L. Starting in July 1994 , consecutive patients with intracerebral hemorrhage have been enrolled through the Massachusetts General Hospital emergency department as part of a longitudinal cohort study ( 23 ) . To vali date our automated search strategy , we compared our case-patient list with the list of patients identified through the cohort study and found that our search strategy missed only 4 patients with intracerebral hemorrhage . We obtained data on patient date of birth , sex , and ethnicity from computerized records . The type of hemorrhage ( intracerebral , subdural , subarachnoid , intraventricular , or epidural ) was determined through review of radiology reports . Data on presenting symptoms , history of minor head trauma , concomitant aspirin use , and disposition status were obtained from review of the admission medical record and were recorded on a st and ardized data collection form . We recorded the INR measurement obtained closest to the onset of symptoms . If an INR was not available or fresh frozen plasma or vitamin K was administered before the measurement , we considered INR data missing . We review ed medical charts for documentation of the following comorbid conditions : history of cerebrovascular disease ( defined as previous ischemic stroke or carotid artery disease ) , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , and cancer ( excluding nonmelanoma skin cancer ) . Controls Controls were sample d from patients managed by the Massachusetts General Hospital Anticoagulation Management Services clinic , which followed approximately 1000 patients receiving anticoagulation for atrial fibrillation at any given time during the study period . All patients who were followed in the anticoagulation clinic , received anticoagulation for atrial fibrillation , and had an INR measurement obtained in the same month and year as the given case date were assigned a r and om number . Six controls per case-patient were then r and omly selected . We matched case- patients to controls by INR date to account for any technical changes in INR testing that may have occurred over time . Because of this sampling method , an individual patient could potentially serve as a control for more than 1 case-patient ( 24 ) . Like case- patients , controls were 18 years of age or older ; were receiving anticoagulation for atrial fibrillation ; and had no documented rheumatic heart disease , mitral stenosis , or valve replacement . We sought data on potential confounders of the association of age , INR , and risk for intracranial hemorrhage , focusing on relevant comorbid conditions and combined use of aspirin with warfarin . We review ed available computerized discharge summaries , outpatient clinic notes , and medication lists from up to 2 years before the admission date . If combination warfarin and aspirin use was not documented , patients were considered to not be taking aspirin . Statistical Analysis Case- patients were categorized by type of hemorrhage : intracerebral , subdural , and other ( subarachnoid , intraventricular , or epidural ) . Clinical differences between types of hemorrhage were compared by using the KruskalWallis test for continuous variables ( age and INR ) and chi-square tests for categorical variables . We compared case- patients with controls by using multivariable conditional logistic regression , matching on INR date . Patient age was divided into 5-year intervals that were coded as indicator variables , and the odds of intracranial hemorrhage for each interval were compared with the odds of hemorrhage at a referent age of 70 to 74 years . The INR was divided into a set of ordered intervals that were coded as indicator variables . The relative odds for intracranial hemorrhage at each interval were calculated by using an INR of 2.0 to 3.0 as the referent category . In addition to age , INR , sex , and ethnicity , the following variables were included in the multivariable models to control for potential confounding effects of clinical factors and aspirin use : cerebrovascular disease , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , cancer , and concomitant aspirin use . If no records were available for review , comorbid conditions and aspirin use were coded as missing . We used multiple imputations for missing data on ethnicity , comorbid conditions , and aspirin use ( 25 ) . We tested for interactions between age and INR and comorbid conditions using 2-way interactions . None of the interaction terms were included in the model if they were not statistically significant when tested collectively . We tested the model 's goodness of fit using the HosmerLemeshow method ( 26 ) . Because the hospital 's anticoagulation clinic did not follow some case- patients before the event , and since factors relating to differences in outpatient care and monitoring could have confounded our analyses , we repeated these analyses in the subgroup of case- patients managed by the anticoagulation clinic . These restricted analyses The aim of the study was to evaluate the effect of two antithrombotic therapies on platelet function and on coagulation in patients with nonvalvular atrial fibrillation ( NVAF ) . Twenty patients with NVAF were treated with aspirin ( 300 mg/day ) and clopidogrel ( 75 mg/day ) for 2 weeks immediately followed by oral anticoagulation ( target international normalized ratio 2.0–3.0 ) . Parameters of platelet function and coagulation were evaluated before antithrombotic therapy , at the end of aspirin plus clopidogrel and during subsequent anticoagulation treatment . Aspirin plus clopidogrel significantly inhibited platelet aggregation , fibrinogen receptor activation and release of P-selectin and prolonged in vitro bleeding time ( p < 0.01 ) . Coagulation parameters ( platelet-dependent thrombin generation , antithrombin III , thrombin-antithrombin III complex , prothrombin fragment 1 + 2 ) were not significantly affected . During the subsequent oral anticoagulation phase platelet function was not substantially reduced ; however , coagulation parameters were significantly inhibited ( p < 0.001 ) . The results indicate that combined antiplatelet therapy is superior to aspirin monotherapy in inhibiting platelet function but does not seem to substantially modulate coagulation cascade in patients with NVAF Background and Purpose — Stroke risk increases with age in patients who have nonvalvular atrial fibrillation . It is uncertain whether the efficacy of stroke prevention therapies in atrial fibrillation changes as patients age . The objective of this study was to determine the effect of age on the relative efficacy of oral anticoagulants ( OAC ) and antiplatelet ( AP ) therapy ( including acetylsalicylic acid and triflusal ) on ischemic stroke , serious bleeding , and vascular events in patients with atrial fibrillation . Methods — This is an analysis of the Atrial Fibrillation Investigators data base , which contains patient level- data from r and omized trials of stroke prevention in atrial fibrillation . We used Cox regression models with age as a continuous variable that controlled for sex , year of r and omization , and history of cerebrovascular disease , diabetes , hypertension , and congestive heart failure . Outcomes included ischemic stroke , serious bleeding ( intracranial hemorrhage or systemic bleeding requiring hospitalization , transfusion , or surgery ) , and cardiovascular events ( ischemic stroke , myocardial infa rct ion , systemic embolism , or vascular death ) . Results — The analysis included 8932 patients and 17 685 years of observation from 12 trials . Patient age increased risk of ischemic stroke ( adjusted hazard ratio per decade increase 1.45 ; 95 % CI , 1.26 to 1.66 ) , serious bleeding ( 1.61 ; 1.47 to 1.77 ) , and cardiovascular events ( 1.43 ; 1.33 to 1.53 ) . Compared with placebo , OAC and AP significantly reduced the risk of ischemic stroke ( OAC , 0.36 ; 0.29 to 0.45 ; AP , 0.81 ; 0.72 to 0.90 ) and cardiovascular outcomes ( OAC , 0.59 ; 0.52 to 0.66 ; AP , 0.81 ; 0.75 to 0.88 ) , whereas OAC increased risk of serious bleeding ( 1.56 ; 1.03 to 2.37 ) . The relative benefit of OAC versus placebo or AP did not vary by patient age for any outcome . Compared with placebo , the relative benefit of AP  for preventing ischemic stroke decreased significantly as patients aged ( P=0.01 ) . Conclusions — As patients with atrial fibrillation age , the relative efficacy of AP to prevent ischemic stroke appears to decrease , whereas it does not change for OAC . Because stroke risk increases with age , the absolute benefit of OAC increases as patients get older Background Decision aids are often advocated as a means to assist patient and health care provider decision making when faced with complicated treatment or screening decisions . Despite an exponential growth in the availability of decision aids in recent years , their impact on long-term treatment decisions and patient adherence is uncertain due to a paucity of rigorous studies . The choice of antithrombotic therapy for nonvalvular atrial fibrillation ( NVAF ) is one condition for which a trade-off exists between the potential risks and benefits of competing therapies , and the need to involve patients in decision making has been clearly identified . This study will evaluate whether an evidence -based patient decision aid for patients with NVAF can improve the appropriateness of antithrombotic therapy use by patients and their family physicians . Design A multi-center , two-armed cluster r and omized trial based in community family practice s in which patients with NVAF will be r and omized to decision aid or usual care . Patients will receive one of four decision aids depending on their baseline stroke risk . The primary outcome is the provision of " appropriate antithrombotic therapy " at 3 months to study participants ( appropriateness defined as per the 2001 American College of Chest Physicians recommendations for NVAF ) . In addition , the impact of this decision aid on patient knowledge , decisional conflict , well-being , and adherence will be assessed after 3 months , 6 months , and 12 months BACKGROUND AND PURPOSE Although the efficacy of anticoagulant therapy for primary prevention of stroke in patients with nonvalvular atrial fibrillation ( NVAF ) has been established , efficacy of antiplatelet therapy for low-risk patients is disputable in Japanese patients because of the frequent hemorrhagic complications . We examined the efficacy and safety of aspirin therapy in Japanese patients with NVAF in a prospect i ve r and omized multicenter trial . METHODS Patients with NVAF were r and omized to an aspirin group ( aspirin at 150 to 200 mg per day ) or a control group without antiplatelet or anticoagulant therapy . Primary end points included cardiovascular death , symptomatic brain infa rct ion , or transient ischemic attack . RESULTS A total of 426 patients were r and omized to aspirin group and 445 to no treatment . The trial was stopped earlier because there were 27 primary end point events ( 3.1 % per year ; 95 % CI , 2.1 % to 4.6 % per year ) in the aspirin group versus 23 ( 2.4 % per year ; 95 % CI , 1.5 % to 3.5 % per year ) in the control group , suggesting a low possibility of superiority of the aspirin treatment for prevention of the primary end point . In addition , treatment with aspirin caused a marginally increased risk of major bleeding ( 7 patients ; 1.6 % ) compared with the control group ( 2 patients ; 0.4 % ; Fisher exact test P=0.101 ) . CONCLUSIONS For prevention of stroke in patients with NVAF , aspirin at 150 to 200 mg per day does not seem to be either effective or safe . Further prospect i ve studies are needed to determine the best preventive therapy for cerebrovascular events in Japanese patients with NVAF BACKGROUND Real-world data on patients ' and physicians ' values related to the use of oral anticoagulant ( OAC ) therapy for stroke prevention in patients with nonvalvular atrial fibrillation are currently lacking . We sought to assess the values , preferences , and experience of patients who receive OAC therapy , and of physicians who prescribe OAC therapy .  METHODS A national survey of r and omly selected patients ( n = 266 ) and physicians ( n = 178 ) was conducted between May and September 2014 . Each was asked to evaluate the importance of individual  OAC  attributes and identify which of 2 medication profiles they would prefer ( individual attributes were progressively modified to determine which were the most valued and /or influenced treatment choice ) . Medication adherence and prescription practice was also assessed . RESULTS The preferences of patients and physicians regarding OAC therapy differed but largely focused on characteristics related to safety and , to a lesser extent , efficacy . When based solely on the basis of the attribute profile ( blinded to the specific agent ) , physicians were more likely to select apixaban ( 61 % ) , whereas patients showed no significant preference among apixaban , rivaroxaban , and warfarin . Despite this , 49 % of physicians spontaneously stated rivaroxaban as their preferred agent ( vs 25 % apixaban ) . Patients prescribed and taking once daily medications ( rivaroxaban or warfarin ) showed better compliance with their OAC therapy ( approximately 30 % of twice daily medications being taken once daily , with significantly more missed doses compared with once daily medications ) . CONCLUSIONS Real-world prescriptions do not reflect reported values , which suggests that other factors influence patient-physician decision-making around OAC therapy . Data on self-reported adherence to OAC therapy and discordance in the use of OACs from prescribed regimens are concerning and warrant further investigation Background and Purpose — Whether intracerebral hemorrhage ( ICH ) survivors should restart antithrombotic drugs is unknown . We analyzed the frequency of restarting antithrombotic drugs  in ICH survivors who had taken prophylactic antithrombotic drugs in atrial fibrillation or after thromboembolic disease in 5 cohorts and explored factors associated with doing so . Methods — We compared the characteristics and proportions of patients taking antithrombotic drugs at ICH onset and discharge in 4 hospital-based cohorts ( Lille , France , n=542 ; Utrecht , The Netherl and s , n=389 ; multicenter Clinical Relevance of Microbleeds in Stroke-2 ( CROMIS-2 ) ICH , United Kingdom , n=667 ; and Amsterdam , The Netherl and s , n=403 ) and 1 community-based study ( Lothian , Scotl and , n=137 ) , using bivariate analyses . We sought characteristics associated with restarting using bivariate and multivariable logistic regression analyses . Results — A total of 942 ( 44 % ) patients with ICH took  antithrombotic drugs  at hospital admission ( no difference between cohorts ) .  Antithrombotic drugs  were restarted in 96 ( 20 % ) of the 469 survivors who had taken antithrombotic drugs for secondary prevention or atrial fibrillation , but this proportion differed when stratified by the cohort of origin ( Lille , 18 % ; Utrecht , 45 % ; Lothian , 15 % ; CROMIS-2 ICH , 11 % ; Amsterdam , 20 % ; P<0.001 ) and by type of antithrombotic drug pre-ICH ( 14 % in patients with previous antiplatelet drugs versus 26 % in patients with previous vitamin K antagonists and 41 % in patients with both drugs ; P<0.001 ) . We did not find other consistent , independent associations with restarting antithrombotic drugs . Conclusions — The variation in clinical practice and lack of consistent associations with restarting antithrombotic drugs after ICH reflect current knowledge and support the need for r and omized controlled trials to resolve this dilemma Background : For patients who survive intracerebral haemorrhage ( ICH ) during treatment with oral anticoagulation ( OAC )  , the balance between the benefits and risks of restarting OAC is unclear . The decision to restart OAC or to start antiplatelet therapy in these patients therefore poses a dilemma for all physicians involved . We assessed the long-term outcome of patients who did or did not restart antithrombotic therapy after OAC-associated ICH . Methods : We conducted a retrospective follow-up study of all patients discharged from our institution after OAC-associated ICH over a 10-year period . Data on the use of OAC or platelet inhibitors and the occurrence of vascular events during follow-up were assessed through question naires and patient files . The primary outcome was recurrent fatal or non-fatal stroke . Secondary outcomes were the occurrence of other haemorrhagic , thrombotic or thromboembolic events . With patients without antithrombotic treatment as reference , we calculated incidence ratios with corresponding 95 % confidence intervals ( CI ) for treatment with OAC and for treatment with antiplatelet therapy . Results : We included 38 patients , of whom 21 ( 55 % ) died during a mean follow-up of 3.5 years . The medication regime changed frequently during follow-up , illustrated by the fact that two thirds of the patients who had resumed OAC within 2 months of ICH terminated this at later points in time . Two recurrent strokes occurred during 35.4 patient-years without antithrombotic medication , 7 during 63.8 patient-years on antiplatelet medication ( incidence ratio 1.9 ; 95 % CI , 0.4 - 9.4 ) , and 3 during 19.5 patient-years on OAC ( incidence ratio 2.7 ; 95 % CI , 0.5 - 16.3 ) . There was only 1 recurrent ICH , which occurred during treatment with OAC . Conclusion : In this observational study , no significant difference in the primary outcome measure was found between the treatment groups , but there was a tendency towards a higher long-term risk of any stroke in patients who resumed OAC or started antiplatelet therapy . However , based on these results it is difficult to draw any concrete conclusions or make any strong recommendations . A r and omized trial to assess the optimal long-term strategy after OAC-related ICH is warranted . Based on the point estimates of our study , such a trial should involve at least 300 patient-years of follow-up Due to heightened risk for thromboembolic complications , nonvalvular atrial fibrillation ( NVAF ) presents an absolute indication for long-term oral anticoagulation therapy . This was an observational , analytical , r and omised , one-year clinical study , conducted in the Blood Transfusion Institute Sarajevo , Bosnia & Herzegovina . The aim of this study was to present the oral anticoagulation treatment in terms of International normalised ratio ( INR ) monitoring and warfarin/acenocoumarol dose titration in 117 patients with NVAF .  INR values , the doses of warfarin and acenocoumarol  , as well as the tendency and adequacy of their changes were monitored . Percentages of the therapeutic INR values were 51,77 % and 53,62 % , subtherapeutic 42,84 % and 35,86 % , and supratherapeutic 5,39 % and 10,53 % for the warfarin and acenocoumarol treatment , respectively . The average total weekly doses ( TWD ) which most frequently achieved the therapeutic INR values were 27,89+/-12,34 mg and 20,44+/-9,94 mg , for warfarin and acenocoumarol , respectively . The dose changes with the INR values 1,7 or lower/3,3 or higher were omitted in 13,46 % and 15,63 % , and with the INR values 1,8 - 3,2 were noted in 8,62 % and 13,48 % of all the check-up visits in the warfarin and acenocoumarol group , respectively . The annual dose changes were noted in 24,65 % and 31,41 % , and the daily dose changes in 74,43 % and 73,36 % of all the check-up visits of warfarin and acenocoumarol group , respectively . We can conclude that the management of the oral anticoagulation treatment in our country is in accordance with the relevant recommendations , but with the present tendency toward underdosing and unnecessary frequent dose changing
In addition , 19 letters to the editor/ review s/editorials/experts ' surveys/experts ' opinion were used for discussion purpose s. Conclusions NVAF is highly prevalent among ICH survivors .
The risks of IS , recurrent ICH , and mortality are heightened in this group .
Most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted .
Background We summarize the existing evidence on the potential benefit of oral anticoagulation ( OAC ) in intracerebral hemorrhage ( ICH ) survivors with nonvalvular atrial fibrillation ( NVAF ) .