Background A number of studies have demonstrated the efficacyof oral anticoagulant therapy in reducing the risk of strokeand systemic embolism in patients with nonrheumatic atrial fibrillation.However, both the targeted and the actual levels of anticoagulationdiffered widely among the studies, and a number of studies failedto report standardized prothrombin-time ratios as internationalnormalized ratios (INRs). We therefore performed an analysisto determine the intensity of oral anticoagulant therapy innonrheumatic atrial fibrillation that provides the best balancebetween the prevention of thromboembolism and the occurrenceof bleeding complications.
Methods We calculated INR-specific incidence rates for bothischemic and major hemorrhagic events occurring in 214 patientswho received anticoagulant therapy in the European Atrial FibrillationTrial, a secondary-prevention trial in patients with nonrheumaticatrial fibrillation and a recent episode of minor cerebral ischemia.
Results The optimal intensity of anticoagulation was found tolie between an INR of 2.0 and an INR of 3.9. No treatment effectwas apparent with anticoagulation below an INR of 2.0. The rateof thromboembolic events was lowest at INRs from 2.0 to 3.9,and most major bleeding complications occurred with treatmentat intensities with INRs of 5.0 or above.
Conclusions To achieve optimal levels of anticoagulation withthe lowest risk in patients with atrial fibrillation and a recentepisode of cerebral ischemia, the target value for the INR shouldbe set at 3.0, and values below 2.0 and above 5.0 should beavoided.
Source Information
Address reprint requests to Dr. Peter J. Koudstaal at the Department of Neurology, University Hospital Rotterdam Dijkzigt, 40 Dr. Molewaterplein, 3015 GD Rotterdam, the Netherlands.
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