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CLINICAL STUDIES

Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy

Robert G. Hart, MD^a, Lesly A. Pearce, MS, Robert M. Rothbart, MD, FACC, John H. McAnulty, MD, FACC, Richard W. Asinger, MD, FACC^||, Jonathan L. Halperin, MD, FACC^¶ for the Stroke Prevention in Atrial Fibrillation Investigators

^a University of Texas Health Science Center, San Antonio, Texas, USA
Axio Research Corporation, Seattle, Washington, USA
LeBauer Cardiology Associates, Greensboro, North Carolina, USA
Oregon Health Sciences University, Portland, Oregon, USA
^|| Hennepin County Medical Center, Minneapolis, Minnesota, USA
^¶ Mt. Sinai Medical Center, New York, New York, USA

Manuscript received March 4, 1999; revised manuscript received July 8, 1999, accepted September 10, 1999.

Reprint requests and correspondence: Dr. Robert G. Hart, Department of Medicine (Neurology), University of Texas HSC, 7703 Floyd Curl Drive, San Antonio, Texas 78284
HartR{at}uthscsa.edu

OBJECTIVE

This study was performed to characterize the risk of stroke in elderly patients with recurrent intermittent atrial fibrillation (AF).

BACKGROUND

Although intermittent AF is common, relatively little is known about the attendant risk of stroke.

METHODS

A longitudinal cohort study was performed comparing 460 participants with intermittent AF with 1,552 with sustained AF treated with aspirin in the Stroke Prevention in Atrial Fibrillation studies and followed for a mean of two years. Independent risk factors for ischemic stroke were identified by multivariate analysis.

RESULTS

Patients with intermittent AF were, on average, younger (66 vs. 70 years, p < 0.001), were more often women (37% vs. 26% p < 0.001) and less often had heart failure (11% vs. 21%, p < 0.001) than those with sustained AF. The annualized rate of ischemic stroke was similar for those with intermittent (3.2%) and sustained AF (3.3%). In patients with intermittent AF, independent predictors of ischemic stroke were advancing age (relative risk [RR] = 2.1 per decade, p < 0.001), hypertension (RR = 3.4, p = 0.003) and prior stroke (RR = 4.1, p = 0.01). Of those with intermittent AF predicted to be high risk (24%), the observed stroke rate was 7.8% per year (95% confidence interval 4.5 to 14).

CONCLUSIONS

In this large cohort of AF patients given aspirin, those with intermittent AF had stroke rates similar to patients with sustained AF and similar stroke risk factors. Many elderly patients with recurrent intermittent AF have substantial rates of stroke and likely benefit from anticoagulation. High-risk patients with intermittent AF can be identified using the same clinical criteria that apply to patients with sustained AF.

Abbreviations and Acronyms   AF = atrial fibrillation   CI = confidence interval   INR = international normalized ratio   RR = relative risk   SPAF = Stroke Prevention in Atrial Fibrillation   TIA = transient ischemic attack

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