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World J Cardiol. May 26, 2017; 9(5): 422-428
Published online May 26, 2017. doi: 10.4330/wjc.v9.i5.422
Empirical anticoagulation for patients in sinus rhythm at high risk of ischaemic stroke: A review of current literature
Irma Battipaglia, James O’Neill, Andrew J Hogarth, Muzahir H Tayebjee
Irma Battipaglia, Department of Cardiovascular Diseases, Catholic University of the Sacred Heart “A. Gemelli” Hospital, 00168 Rome, Italy
James O’Neill, Andrew J Hogarth, Muzahir H Tayebjee, Department of Cardiology, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
Author contributions: Battipaglia I wrote the initial manuscript; O’Neill J revised the manuscript, added additional material and designed Table 1; Hogarth AJ and Tayebjee MH devised the concept for the manuscript, advised on appropriate references and reviewed the manuscript prior to submission.
Conflict-of-interest statement: O’Neill J has received a fellowship from St. Jude Medical. Tayebjee MH has received research/travel grants from St. Jude Medical, Biosense Webster, Medtronic and Boehringer Ingelheim.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Muzahir H Tayebjee, MB ChB (Hons), MRCP, MD, Department of Cardiology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom. mhtayebjee@hotmail.com
Telephone: +44-113-3926619 Fax: +44-113-3923981
Received: September 19, 2016
Peer-review started: September 23, 2016
First decision: November 21, 2016
Revised: March 9, 2017
Accepted: March 21, 2017
Article in press: March 22, 2017
Published online: May 26, 2017
Processing time: 242 Days and 19.8 Hours
Abstract

Ischaemic stroke is one of the commonest causes of morbidity and mortality worldwide and around a fifth of events can be attributed to a cardioembolic source. This is typically due to atrial fibrillation (AF), the most common sustained cardiac arrhythmia. However, AF can, at times, be difficult to detect due to a relative lack of symptoms and the fact that it can be paroxysmal in nature. Studies have shown that diagnosis of AF improves as the length of cardiac monitoring increases. However, prolonged cardiac monitoring is not a cost-effective way of diagnosing AF. Therefore, an alternative approach may be to empirically anticoagulate individuals who are at high risk of stroke. This article summarises current evidence surrounding stroke risk prediction, the use of anticoagulation in the secondary prevention of stroke and its use in the primary prevention of stroke in high risk groups with the aim of determining whether empirical anticoagulation is a safe and effective strategy.

Keywords: Anticoagulation; Ischaemic stroke; Atrial fibrillation; CHA2DS2VASc; CHADS-2; Heart failure; Coronary artery disease; Peripheral arterial disease

Core tip: This is a contemporary review exploring issues related to the risk of stroke and use of anticoagulation in patients who are in sinus rhythm (SR). It examines the prediction of stroke in patients without known atrial fibrillation (AF), the identification of AF in patients following stroke and the use of anticoagulation in post-stroke patients seemingly in SR or those at high-risk of stroke. The main findings are: (1) prolonged cardiac monitoring increases the rate of AF diagnosis but is not cost-effective; (2) current risk stratification schemes such as CHA2DS2VASc can identify those in sinus rhythm who are at risk of stroke; and (3) further research is required to determine whether individuals at high-risk of stroke would benefit from anticoagulation.