Sign Up for a Free Account
  • Updated 11.23.2023
  • Released 06.20.1996
  • Expires For CME 11.23.2026

Stroke associated with atrial fibrillation



Stroke is the leading cause of disability in the United States, with approximately 795,000 people experiencing a new or recurrent stroke each year (85). Cardioembolism is a particularly disabling stroke subtype that accounts for 20% to 30% of all stroke cases. Observational studies demonstrated that almost half of the cardioembolic strokes are related to atrial fibrillation. In this article, the authors discuss the association of atrial fibrillation with stroke, the role of anticoagulation in stroke prevention, the available risk stratification tools, and the pathogenic mechanisms of thrombus formation associated with this cardiac arrhythmia.

Key points

• Atrial fibrillation confers a 3- to 5-fold increase in stroke risk and accounts for 15% to 30% of all ischemic strokes.

• Prolonged cardiac monitoring is superior to short-term monitoring for the detection of occult atrial fibrillation.

• Patients with atrial fibrillation and a CHA2DS2-VASc score of 0 in men and 1 in women have a low stroke risk and do not require treatment with antithrombotics.

• Patients with atrial fibrillation and a CHA2DS2-VASc score of 1 in men and 2 in women have an intermediate stroke risk, and treatment with oral anticoagulants should be initiated.

• Patients with atrial fibrillation and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women are at high risk for stroke, and treatment with anticoagulants is recommended.

• Direct thrombin or factor Xa inhibitors are non-inferior to warfarin in the prevention of stroke or systemic embolism, have lower incidence of major hemorrhagic complications, and are the preferred choice of anticoagulation in patients with atrial fibrillation.

• The addition of aspirin to anticoagulation is only indicated in patients who have concomitant coronary artery disease.

Historical note and terminology

As early as 1628, Harvey had observed undulation in the right atrium of a dying animal heart (62); in 1874, Vulpian reported uncoordinated twitching of the atrium, "fremissement fibrillaire" after application of an electrical current (89). Nothnagel published three arterial pulse curves showing irregular heart rates in the mid-1800s and called the arrhythmia "delirium cordis" (64), which was defined by the complete irregularity of heartbeats continuously changing in "height and tension." However, the association between these atrial fibrillary contractions and the irregular pulse was not formally made until 1907 (18).

In 1940, Karl Paul Link synthesized dicumarol, a substance found in spoiled sweet clover known to cause a hemorrhagic disease in cattle; in 1947, its use was advocated for the prevention of cardiac embolism in patients with rheumatic atrial fibrillation (95). However, the risk of stroke in patients with chronic nonvalvular atrial fibrillation was generally believed to be too small to require medication. It was not until 1978 that the results of the Framingham Study clearly demonstrated an increase in stroke incidence in patients with chronic nonrheumatic atrial fibrillation (93). Vitamin K antagonists, including warfarin, have been the treatment of choice for the prevention of stroke or systemic embolism in patients with atrial fibrillation for many decades. However, randomized placebo-control studies and large patient-level network meta-analyses demonstrated more favorable efficacy and safety profiles of different non-vitamin K antagonist oral anticoagulants in the treatment of nonvalvular atrial fibrillation compared with warfarin and are now the recommend treatment of choice.

This is an article preview.
Start a Free Account
to access the full version.

  • Nearly 3,000 illustrations, including video clips of neurologic disorders.

  • Every article is reviewed by our esteemed Editorial Board for accuracy and currency.

  • Full spectrum of neurology in 1,200 comprehensive articles.

  • Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink®, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660



ISSN: 2831-9125