High frequency of anticoagulation management errors preceding ischaemic strokes in atrial fibrillation

Background: Anticoagulants are recommended to prevent cardioembolic stroke in most patients with atrial fibrillation (AF). Management errors with anticoagulation and use of aspirin instead of anticoagulants have been documented worldwide, especially with vitamin K antagonists.

Aims: To assess the rate of anticoagulant mismanagement errors in patients admitted with ischaemic stroke and the clinical correlates with stroke outcomes in the era of non-vitamin K oral anticoagulants.

Methods: We performed a retrospective analysis of patients admitted with ischaemic stroke and history of AF to a single-centre tertiary hospital stroke unit in Melbourne, Australia, between January 2016 and June 2019. We assessed management errors as defined using European Heart Rhythm Association criteria with anticoagulation in the 2 weeks prior to the index stroke.

Results: A total of 306 patients with AF and ischaemic stroke was included, of whom 196 (64%) had management errors. Patients with management errors were older (median age 84 vs 81 years; P = 0.002) and more often female (53% vs 38%; P = 0.02). Of those with management errors, 74 (37%) were not prescribed any anticoagulation despite increased stroke risk and absence of contraindications and 40 (20%) had anticoagulation inappropriately ceased. Mortality at 3 months was 32% in those with management errors, compared with 17% in the appropriately anticoagulated group (P = 0.005).

Conclusions: Inappropriate management of anticoagulants is present in the majority of acute ischaemic stroke in the 2 weeks preceding the event and is linked to higher mortality. Improved anticoagulation practice has the potential to substantially reduce stroke rates in patients with AF.