Rates of Ischemic Stroke During Warfarin Treatment for Atrial Fibrillation

Background and Purpose-Recent evidence suggests that there may be an increased risk of ischemic stroke immediately after warfarin initiation. We examined the rate of ischemic stroke among patients with atrial fibrillation newly started on warfarin therapy. Methods-We conducted a population-based cohort study among Ontario residents aged >= 66 years with atrial fibrillation who received warfarin between April 1, 1997, and March 31, 2010. Each patient was followed up for <= 5 years in 30-day intervals. For each interval, we determined the rate of ischemic stroke. Results-After 5 years, the cumulative incidence of ischemic stroke among new users of warfarin (n=148446) was 4.0% (n=6006). The risk was highest during the first 30 days after initiation (6.0% per person-year; 95% confidence interval, 5.5%-6.4%) compared with the remainder of follow-up (1.6% per person-year; 95% confidence interval, 1.5%-1.6%), and increased with higher baseline CHADS 2 (congestive heart failure, hypertension, age >= 75 years, diabetes, previous stroke) scores. Less frequent monitoring may have contributed. Conclusions-In a large cohort of older patients with atrial fibrillation, we observed the highest rate of ischemic stroke in the first 30 days after warfarin initiation. Although causation cannot be established given the observational nature of this study, our findings highlight the need for future research in this population.