Mark J. Alberts, MD


February 13, 2012

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Hello. I am Dr. Mark Alberts, Professor of Neurology and Head of Stroke at Northwestern University. Welcome to this Medscape stroke update. Today, I would like to update you about the results of several studies reported at the International Stroke Conference hosted by the American Heart Association.

The first is the WARCEF study.[1] This was a National Institutes of Health-sponsored prospective randomized trial of warfarin vs aspirin in people who had a diminished ejection fraction of less than 35%. The goal was to see whether warfarin would be better or worse than aspirin in this group of patients for the prevention of stroke and subsequent vascular events.

After about 6 years of treatment, the investigators found no significant overall advantage to long-term warfarin vs aspirin for prevention of vascular events. In some patients, a slight trend in favor of warfarin for preventing stroke was seen, but when bleeding and other events were added into the mix, the overall benefit was not significant.

Of course, this only tells us about patients with ejection fractions less than 35%. What about patients with severely reduced ejection fractions? We don't know much about them, and we will have to wait for subsequent analyses of particular subgroups. In addition, there may have been some bias in terms of patients with very low ejection fractions. They might not have been randomized, but treated with warfarin anyway. For the large group, however, with an ejection fraction less than 35%, the bottom line is no benefit of warfarin over aspirin. Therefore, the treatment of choice appears to be aspirin.

Will the new novel oral anticoagulants be better than warfarin? That has yet to be studied or proven. Thank you very much for listening to this Medscape stroke update.


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