Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA

BMJ Open. 2019 Jul 24;9(7):e028387. doi: 10.1136/bmjopen-2018-028387.


Objective: We report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients with newly diagnosed AF, in a cohort of patients who presented with ischaemic stroke or transient ischaemic attack (TIA) not previously treated with anticoagulation.

Design: We reviewed cross-sectional baseline demographic and clinical data from a prospective observational cohort study, (CROMIS-2).

Setting: Patients were recruited from 79 hospital stroke centres throughout the UK and one centre in the Netherlands.

Participants: Patients were eligible if they were adults who presented with ischaemic stroke or TIA and AF and had not been previously treated with oral anticoagulation.

Main outcome measures: Proportion of patients with known AF before index ischaemic stroke or TIA from a cohort of patients who have not been previously treated with oral anticoagulation. Secondary analysis includes the comparison of CHA2DS2-VASc and HAS-BLED scores and other demographics and risk factors between those with newly diagnosed AF and those with previously known AF.

Results: Of 1470 patients included in the analysis (mean age 76 years (SD 10)), 622 (42%) were female; 999 (68%) patients had newly diagnosed AF and 471 (32%) patients had known AF. Of the 471 patients with known AF, 68% had a strong indication for anticoagulation and 89% should have been considered for anticoagulation based upon CHA2DS2-VASc score. Patients with known AF were more likely to have a prior history of dementia (4% vs 2%, p=0.02) and had higher HAS-BLED scores (median 3 vs 2). CHA2DS2-VASc, other risk factors and demographics were similar.

Conclusions: About 1/3 of patients who present with stroke and have AF who have not been treated with oral anticoagulation have previously known AF. Of these patients, at least 68% were not adequately treated with oral anticoagulation.

Trial registration number: NCT02513316.

Keywords: anticoagulation; atrial fibrillation; stroke.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / epidemiology
  • Comorbidity
  • Cross-Sectional Studies
  • Factor Xa Inhibitors / therapeutic use*
  • Female
  • Humans
  • Ischemic Attack, Transient / etiology
  • Ischemic Attack, Transient / prevention & control*
  • Male
  • Prospective Studies
  • Risk Adjustment
  • Risk Assessment / methods
  • Stroke / etiology
  • Stroke / prevention & control*


  • Factor Xa Inhibitors

Associated data

  • ClinicalTrials.gov/NCT02513316