Atrial fibrillation and silent infarcts, is anticoagulation enough?

By Dr Jonathan Shurlock

The use of anticoagulation to reduce the risk of stroke in patients with AF is widespread, often protocol driven, and guided by risk scores. Recent research by Kühne et al. has highlighted persistent risk despite anticoagulation in this cohort of patients.

The authors enrolled 1,227 patients with AF, from a prospective cohort study (Swiss-AF). Participants underwent baseline magnetic resonance imaging (MRI) of the brain and repeat imaging after 2 years. Outcome measures were quantified by the presence of infarcts on repeat MRI, and further characterised as with or without (silent infarct) clinical evidence of stroke or transient ischaemic attack (TIA). Secondary measures included cognitive decline as assessed by changes in the Cognitive construct score.

The mean age of participants was 71 and 89.9% were being treated with anticoagulation. Over 2 years of follow-up 28 patients (2.3%) suffered with clinical stroke or TIA. 68 patients (5.5%) had evidence of one or more infarcts on repeat imaging, of these patients 88.2% were anticoagulated. Patients who had suffered with brain infarcts, whether overt or silent, showed a larger decline in cognition than those without.

These findings are highly relevant, particularly when considering the patient centred outcome of cognitive decline. The discussed data highlights the possible limits to the protective effect (on cognition) of standard anticoagulation in AF. These limitations are essential to consider in order to allow safe and accurate anticoagulation counselling for patients.


  1. Michael Kühne, Philipp Krisai, Michael Coslovsky, Nicolas Rodondi, Andreas Müller et al. for the Swiss-AF Investigators. Silent brain infarcts impact on cognitive function in atrial fibrillation. European Heart Journal, 2022;, ehac020