Pj. Koudstaal et al., OPTIMAL ORAL ANTICOAGULANT-THERAPY IN PATIENTS WITH NONRHEUMATIC ATRIAL-FIBRILLATION AND RECENT CEREBRAL-ISCHEMIA, The New England journal of medicine, 333(1), 1995, pp. 5-10
Background. A number of studies have demonstrated the efficacy of oral
anticoagulant therapy in reducing the risk of stroke and systemic emb
olism in patients with nonrheumatic atrial fibrillation, However, both
the targeted and the actual levels of anticoagulation differed widely
among the studies, and a number of studies failed to report standardi
zed prothrombin-time ratios as international normalized ratios (INRs),
We therefore performed an analysis to determine the intensity of oral
anticoagulant therapy in nonrheumatic atrial fibrillation that provid
es the best balance between the prevention of thromboembolism and the
occurrence of bleeding complications. Methods. We calculated INR-speci
fic incidence rates for both ischemic and major hemorrhagic events occ
urring in 214 patients who received anticoagulant therapy in the Europ
ean Atrial Fibrillation Trial, a secondary-prevention trial in patient
s with nonrheumatic atrial fibrillation and a recent episode of minor
cerebral ischemia. Results. The optimal intensity of anticoagulation w
as found to lie between an INR of 2.0 and an INR of 3.9. No treatment
effect was apparent with anticoagulation below an INR of 2.0, The rate
of thromboembolic events was lowest at INRs from 2.0 to 3.9, and most
major bleeding complications occurred with treatment at intensities w
ith INRs of 5.0 or above. Conclusions. To achieve optimal levels of an
ticoagulation with the lowest risk in patients with atrial fibrillatio
n and a recent episode of cerebral ischemia, the target value for the
INR should be set at 3.0, and values below 2.0 and above 5.0 should be
avoided.