Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients

Thromb Haemost. 2011 Nov;106(5):968-77. doi: 10.1160/TH11-05-0353. Epub 2011 Sep 8.


Atrial fibrillation (AF) carries an increased risk of ischaemic stroke, and oral anticoagulation with warfarin can reduce this risk. The objective of this study was to evaluate the association between time in therapeutic International Normalised Ratio (INR) range when receiving warfarin and the risk of stroke and mortality. The study cohort included AF patients aged 40 years and older included in the UK General Practice Research Database. For patients treated with warfarin we computed the percentage of follow-up time spent within therapeutic range. Cox regression was used to assess the association between INR and outcomes while controlling for patient demographics, health status and concomitant medication. The study population included 27,458 warfarin-treated (with at least 3 INR measurements) and 10,449 patients not treated with antithrombotic therapy. Overall the warfarin users spent 63% of their time within therapeutic range (TTR). This percentage did not vary substantially by age, sex and CHA2DS2-VASc score. Patients who spent at least 70% of time within therapeutic range had a 79% reduced risk of stroke compared to patients with ≤30% of time in range (adjusted relative rate of 0.21; 95% confidence interval 0.18-0.25). Mortality rates were also significantly lower with at least 70% of time spent within therapeutic range. In conclusion, good anticoagulation control was associated with a reduction in the risk of stroke.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anticoagulants / therapeutic use*
  • Atrial Fibrillation / blood
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / mortality*
  • Blood Coagulation / drug effects*
  • Databases as Topic
  • Drug Monitoring / methods
  • Female
  • General Practice
  • Humans
  • International Normalized Ratio
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Odds Ratio
  • Proportional Hazards Models
  • Risk Assessment
  • Risk Factors
  • Stroke / blood
  • Stroke / etiology
  • Stroke / mortality*
  • Stroke / prevention & control*
  • Time Factors
  • Treatment Outcome
  • United Kingdom
  • Warfarin


  • Anticoagulants
  • Warfarin