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A Comparison of Warfarin and Aspirin for the Prevention of Recurrent Ischemic Stroke
Open accessAbstract
BACKGROUND: Despite the use of antiplatelet agents, usually aspirin, in patients who have had an ischemic stroke, there is still a substantial rate of recurrence. Therefore, we investigated whether warfarin, which is effective and superior to aspirin in the prevention of cardiogenic embolism, would also prove superior in the prevention of recurrent ischemic stroke in patients with a prior noncardioembolic ischemic stroke. METHODS: In a multicenter, double-blind, randomized trial, we compared the effect of warfarin (at a dose adjusted to produce an international normalized ratio of 1.4 to 2.8) and that of aspirin (325 mg per day) on the combined primary end point of recurrent ischemic stroke or death from any cause within two years. RESULTS: The two randomized study groups were similar with respect to base-line risk factors. In the intention-to-treat analysis, no significant differences were found between the treatment groups in any of the outcomes measured. The primary end point of death or recurrent ischemic stroke was reached by 196 of 1103 patients assigned to warfarin (17.8 percent) and 176 of 1103 assigned to aspirin (16.0 percent; P=0.25; hazard ratio comparing warfarin with aspirin, 1.13; 95 percent confidence interval, 0.92 to 1.38). The rates of major hemorrhage were low (2.22 per 100 patient-years in the warfarin group and 1.49 per 100 patient-years in the aspirin group). Also, there were no significant treatment-related differences in the frequency of or time to the primary end point or major hemorrhage according to the cause of the initial stroke (1237 patients had had previous small-vessel or lacunar infarcts, 576 had had cryptogenic infarcts, and 259 had had infarcts designated as due to severe stenosis or occlusion of a large artery). CONCLUSIONS: Over two years, we found no difference between aspirin and warfarin in the prevention of recurrent ischemic stroke or death or in the rate of major hemorrhage. Consequently, we regard both warfarin and aspirin as reasonable therapeutic alternatives.
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“In such patients oral vitamin K antagonists are not superior to aspirin but are associated with a higher bleeding risk.512,513”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [512]
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Halabi, C., Colorado, R. A., & Meisel, K. M. (2019) · Wiley eBooks · doi:10.1002/9781118492390.ch17 · Cited by 5
Left Atrial Appendage Closure vs Anticoagulation for Stroke Prevention in Atrial Fibrillation
Turagam, M. K., Halperin, J. L., Granger, C. B., Bhatt, D. L., Velagapudi, P., Dukkipati, S. R., Gurol, M. E., Sartori, S., Nair, D. G., Neužil, P., et al. (2026) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2026.06.033 · Cited by 4
Yang, F., Jiang, W., Bai, Y. M., Han, J., Liu, X., Zhang, G., & Zhao, G. (2015) · BMC Neurology · doi:10.1186/s12883-015-0453-7 · Cited by 4
“Although, traditional anticoagulant has showed effectiveness of recurrent stroke prevention, its use was very limited in patients with ischemic cerebrovascular events because of higher incidence of bleeding events [16–19].”
BackgroundChapter 64 Antithrombotic agents for stroke prevention
Schwartz, N. E., Diener, H., & Albers, G. W. (2008) · Handbook of clinical neurology · doi:10.1016/s0072-9752(08)94064-1 · Cited by 4
Self-citationA Critical Review of Aspirin in the Secondary Prevention of Noncardioembolic Ischaemic Stroke
Inzitari, D., Piccardi, B., & Sarti, C. (2010) · International Journal of Stroke · doi:10.1111/j.1747-4949.2010.00443.x · Cited by 4
Echocardiographic Evaluation of the Patient with a Systemic Embolic Event
Chen, E. W., & Redberg, R. F. (2007) · Elsevier eBooks · doi:10.1016/b978-1-4160-3640-1.50044-7 · Cited by 3
Recurrent Embolic Strokes of Undetermined Source in a Patient with Extreme Lipoprotein(a) Levels
Bulwa, Z. B., Kim, A., Singh, K., Kantorovich, A., & Suhail, F. (2016) · Frontiers in Neurology · doi:10.3389/fneur.2016.00144 · Cited by 4
“Although there is evidence in a subgroup analysis that warfarin may be more efficacious than aspirin among patients with cryptogenic stroke who did not have hypertension and did have embolic infarcts on neuroimaging, we did not initiate anticoagulation due to concern for an increase in major hemorrhages (22, 23).”
BackgroundResultNamini, A., Naylor, M. C., & Koenigsberg, R. A. (2015) · Cited by 4
Stroke Etiologic Classification—Moving From Prediction to Precision
Elkind, M. S. V. (2017) · JAMA Neurology · doi:10.1001/jamaneurol.2016.5926 · Cited by 4
Cryptogenic stroke. A non-diagnosis
Gutiérrez-Zúñiga, R., Fuentes, B., & Díez‐Tejedor, E. (2018) · Medicina Clínica (English Edition) · doi:10.1016/j.medcle.2018.05.041 · Cited by 3
Romero, N., Lupi, K. E., Carter, D., & Malloy, R. J. (2018) · Clinical Therapeutics · doi:10.1016/j.clinthera.2018.09.014 · Cited by 5
Transcatheter Closure of Patent Foramen Ovale
Arfaras-Melainis, A., Palaiodimos, L., & Mojadidi, M. K. (2019) · Interventional Cardiology Clinics · doi:10.1016/j.iccl.2019.05.002 · Cited by 4
Adherence to study drug in a stroke prevention trial"?>
Kiran, A., Viscoli, C. M., Furie, K. L., Gorman, M., & Kernan, W. N. (2020) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/j.jstrokecerebrovasdis.2020.105048 · Cited by 4
Self-citationLundström, A., Rooth, E., Mobarrez, F., Thålin, C., Gigante, B., Laska, A. C., & Wallén, H. (2020) · Thrombosis and Haemostasis · doi:10.1055/s-0040-1721146 · Cited by 4
Patent foramen ovale closure for secondary prevention of cryptogenic stroke
Kolte, D. S., & Palacios, I. F. (2021) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2021.1878026 · Cited by 4
“WARSS was the first randomized controlled study to compare the effect of warfarin and aspirin after prior noncardioembolic ischemic stroke [25].”
BackgroundMethod
Metadata
- Authors
- Mohr, J. P., Thompson, J. L. P., Lazar, R. M., Levin, B., Sacco, R. L., Furie, K. L., Kistler, J. P., Albers, G. W., Pettigrew, L. C., Adams, H. P., Jackson, C. M., & Pullicino, P.
- Affiliations
- Columbia University Irving Medical Center (US)
- Massachusetts General Hospital (US)
- Stanford Medicine (US)
- University of Kentucky (US)
- University of California San Diego (US)
- University at Buffalo, State University of New York (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2001-11-15
- Volume
- 345
- Issue
- 20
- Pages
- 1444-1451
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2027538725
- Cited by
- 1,168
- References
- 39
- Citations by year
- 2026: 9 · 2025: 12 · 2024: 13 · 2023: 22 · 2022: 20 · 2021: 40 · 2020: 24 · 2019: 37 · 2018: 32 · 2017: 33 · 2016: 50 · 2015: 41 · 2014: 54 · 2013: 39 · 2012: 49
- FWCI
- 54.22
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Kent Academic Repository (University of Kent) (submittedVersion)
- Funders
- U.S. Department of Veterans Affairs
- Yale University
- University of Southern California
- Vanderbilt University
- University of Miami
- Wayne State University
- Cleveland Clinic
- Cleveland Clinic Foundation
- Johns Hopkins University
- Hennepin County Medical Center
- University of South Alabama
- York University
- University of Illinois at Urbana-Champaign
- National Institute of Neurological Disorders and Stroke (R01NS028371)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Keywords
- warfarin, aspirin, recurrent ischemic stroke, secondary stroke prevention, antiplatelet therapy, major bleeding, non-cardioembolic stroke, lacunar infarction, cryptogenic stroke, international normalized ratio, anticoagulation
- MeSH terms
- Adult, Aged, Aged, 80 and over, Anticoagulants, Aspirin, Brain Ischemia, Double-Blind Method, Female, Hemorrhage, Humans, Male, Middle Aged, Mortality, Platelet Aggregation Inhibitors, Risk Factors, Warfarin, International Normalized Ratio, Stroke, Secondary Prevention
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