Atrial Fibrillation in Ischemic Stroke

Predicting Response to Thrombolysis and Clinical Outcomes

Gustavo Saposnik, MD, MSc, FAHA, FRCPC; David Gladstone, MD, PhD, FRCPC;
Roula Raptis, MSc; Limei Zhou, PhD; Robert G. Hart, MD FAHA; on behalf of the Investigators
of the Registry of the Canadian Stroke Network (RCSN) and the Stroke Outcomes Research Canada
(SORCan) Working Group

Background and Purpose—Atrial fibrillation (AF) increases the risk of stroke and is associated with poor stroke outcomes.
Limited tools are available to evaluate clinical outcomes and response to thrombolysis in stroke patients with AF.
Methods—We applied the iScore (http://www.sorcan.ca/iscore), a validated risk score, to consecutive patients with an acute
ischemic stroke admitted to stroke centers in the Registry of the Canadian Stroke Network. The main outcome considered
was a favorable outcome (defined as a modified Rankin scale 0–2) at discharge after thrombolysis. Secondary outcomes
included intracerebral hemorrhage, death at 30 days, and at 1 year stratified by terciles of the iScore.
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Results—Among 12 686 patients with an acute ischemic stroke, 2185 (17.2%) had AF. Overall, AF patients had higher risk
of death at 30 days (22.3% versus 10.2%; P<0.0001), 1 year (37.1% versus 19.5%; P<0.0001) and death or disability
at discharge (69.7% versus 54.7%; P<0.0001) compared with non-AF patients. After adjustment, thrombolysis was
associated with a favorable outcome for patients without AF (relative risk, 1.18; 95% CI, 1.10–1.27), but no benefit was
observed for patients with AF (relative risk, 0.91; 95% CI, 0.71–1.17). There was a modestly increased risk of intracranial
hemorrhage (any type) (16.5% versus 11.6%; relative risk, 1.42; 95% CI, 1.05–1.91) after thrombolysis among AF
compared with non-AF patients. In the logistic regression analysis, there was an interaction between tPA and iScore for a
favorable outcome (P-value interaction <0.001). The interaction also was significant (P<0.0012) among patients without
AF, but did not reach significance (P=0.17) in patients with AF.
Conclusions—Stroke patients with AF have higher mortality, greater risk of intracerebral hemorrhage, and a similar response
trend to thrombolysis compared with non-AF patients.  (Stroke. 2013;44:99-104.)
Key Words: atrial fibrillation ◼ iScore ◼ outcomes ◼ risk assessment ◼ stroke ◼ stroke care ◼ thrombolysis

A trial fibrillation (AF) is a major modifiable factor associ-

ated with a 4- to 5-fold increased risk of ischemic stroke.1
The attributable risk of stroke for AF increases with age, from
1.5% for those aged 50 to 59 years to nearly 25% for those
aged ≥80 years.1,2 The risk of stroke and AF both increase
with age, it is anticipated that there will be greater numbers
of patients presenting with an acute stroke and concomitant
AF as the population ages.1 For example, in Canada >70% of
hospitalized stroke patients were ≥70 years of age and over
one third were >80 years.3 Similar figures are observed in the
United States among participating institutions in the Get-with-
the-guidelines.4 Moreover, AF is an independent predictor of
mortality and also associated with poorer outcomes among
stroke patients.5–7
Limited tools are available to predict stroke outcomes in
patients with AF. In previous work, our group showed the
iScore, a validated predictor of outcomes after acute isch-
emic stroke, predicts mortality at 30 days and 1 year, death
and disability at discharge, and death or institutionalization
at discharge.6,7 We also showed the iScore helps estimate the
risk of bleeding and clinical response after thrombolysis.8 The
iScore includes AF, as well as other clinical variables easily
available at the time of the presentation that help categorize
ischemic stroke patients according to their risk of a good or
poor recovery.
Our objectives were (1) to evaluate clinical outcomes in
patients with and without AF using the iScore, and (2) to
determine the ability of the iScore to predict clinical response

Received September 10, 2012; final revision received September 10, 2012; accepted October 2, 2012.
From the Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto,
Ontario, Canada (G.S.); Division of Neurology, Department of Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada (D.G.);
Applied Health Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada (R.R., G.S.); Institute for Clinical
Evaluative Sciences (ICES), Toronto, Ontario, Canada (G.S., L.Z.); Population Health Research Institute (PHRI), McMaster University, Hamilton, Ontario,
Canada (R.G.H.); and Institute of Health Policy, Management and Evaluation (iHPME), University of Toronto, Toronto, Ontario, Canada (G.S.).
We declare that we have participated in the conception, design, analysis, interpretation of the results, drafting the manuscript and made a critical revision
of the manuscript. Statistical expertise: Drs Zhou (statistician) and Saposnik. Dr Zhou had full access to the data.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.112.
676551/-/DC1.
Correspondence to Gustavo Saposnik, MD, MSc, FAHA, FRCPC, Stroke Outcomes Research Center, Department of Medicine, St. Michael’s Hospital,
University of Toronto, 55 Queen St E, Toronto, Ontario, M5C 1R6, Canada. E-mail saposnikg@smh.ca
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.112.676551

99
 100  Stroke  January 2013

Table 1.  Characteristics of Ischemic Stroke Cohort, Stratified by Atrial Fibrillation

Atrial Fibrillation
Characteristic All (n = 12 686) Yes (n=2185) (%) No (n=10 501) (%) P Value
Age, mean (SD), y 72.0±13.8 79.2±9.7 70.5±14.0 <0.001
Age, y
  ≤59 2331 (18.4) 91 (4.2) 2240 (21.3) <0.001
 60–69 2279 (18.0) 225 (10.3) 2054 (19.6)
 70–79 3732 (29.4) 657 (30.1) 3075 (29.3)
  ≥80 4344 (34.2) 1212 (55.5) 3132 (29.8)
Sex
 Female 6026 (47.5) 1226 (56.1) 4800 (45.7) <0.001
Stroke severity <0.001
 Mild 8273 (65.2) 1160 (53.1) 7113 (67.7)
 Moderate 2495 (19.7) 480 (22.0) 2015 (19.2)
 Severe 1564 (12.3) 446 (20.4) 1118 (10.6)
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 Coma 354 (2.8) 99 (4.5) 255 (2.4)

Stroke subtype
 Lacunar 2148 (16.9) 108 (4.9) 2040 (19.4) <0.001
 Nonlacunar 6021 (47.5) 1615 (73.9) 4406 (42.0)
 Undetermined 4517 (35.6) 462 (21.1) 4055 (38.6)
Risk factors
  Coronary disease 3042 (24.0) 791 (36.2) 2251 (21.4) <0.001
  Heart failure 1152 (9.1) 497 (22.7) 655 (6.2) <0.001
  Diabetes mellitus 3238 (25.5) 550 (25.2) 2688 (25.6) 0.678
 Hyperlipidemia 4437 (35.0) 782 (35.8) 3655 (34.8) 0.381
 Hypertension 8643 (68.1) 1641 (75.1) 7002 (66.7) <0.001
  Previous MI 1945 (15.3) 475 (21.7) 1470 (14.0) <0.001
  Current smoker 2469 (19.5) 177 (8.1) 2292 (21.8) <0.001
Comorbid conditions
 Cancer 1244 (9.8) 259 (11.9) 985 (9.4) <0.001
 Dementia 1097 (8.6) 281 (12.9) 816 (7.8) <0.001
  Renal dialysis 111 (0.9) 20 (0.9) 91 (0.9) 0.824
Preadmission disability
 Dependent 2670 (21.0) 694 (31.8) 1976 (18.8) <0.001
  Glucose on admission, mmol/L ≥7.5 4494 (35.4) 832 (38.1) 3662 (34.9) 0.004
tPA administered
 Yes 1696 (13.4) 316 (14.5) 1380 (13.1) 0.099
iScore, 30 d
 Mean±SD 135.43±41.90 164.44±39.48 129.39±39.81 <0.001
iScore, 1 y
 Mean±SD 114.03±31.54 134.82±29.76 109.70±30.16 <0.001
MI indicates myocardial infarction.

and hemorrhagic complications after thrombolysis in stroke
patients with and without AF.
Methods
Study Population
We used the Registry of the Canadian Stroke Network (RCSN) to
identify patients admitted to 12 designated acute stroke centers in
the province of Ontario, Canada between July 1, 2003 and June
30, 2008. Patients with missing baseline characteristics (Canadian
Neurological Scale score, glucose on admission, unique health
identifier) (n=1005; 7.3%) were excluded. Further details on the
RCSN can be obtained from the RCSN report at (http://www.rcsn.
org).6,9 AF is one of the variables systematically collected in the
RCSN. It includes participants with history of AF of any origin or
documented on admission.
The iScore is a prognostic score that estimates functional out-
comes in patients with an ischemic stroke early after hospitalization
using clinical parameters and comorbid conditions (Supplemental
Table 1).6,7 We calculated the iScore for each eligible participant in
the RSCN. Details of the conceptualization of the iScore have been
published elsewhere.6 An online web-based tool (http://www.sorcan.
ca/iscore) and iPhone version are currently available for practical use.
 Saposnik et al   Atrial Fibrillation: The iScore, tPA, and Stroke Outcomes   101

Outcome Measures
Favorable outcome after thrombolysis, the primary outcome measure,
was defined as a modified Rankin scale (mRS) 0 to 2 at discharge
(assessed by members of the stroke team). Secondary outcomes in-
cluded: (1) Poor outcome defined as death that occurred within 30
days or disability at discharge according to on the mRS score of 3
to 5, (2) death at 30 days, (3) death at 1 year, (4) intracerebral hem-
orrhage (ICH) (any type or symptomatic) after thrombolysis, and
(5) discharge home (or same place of residence prior to stroke).
Symptomatic ICH was defined as a neurological deterioration in the
first 36 hours after receiving tPA and documented by neuroimaging.
Statistical Analysis
χ2 tests were used to compare categorical variables; ANOVA or
Kruskal–Wallis tests were used to compare mean and median differ-
ences for continuous variables. We used terciles to determine whether
a higher iScore was associated with poorer outcomes in patients with
and without AF. As identified in a previous study on the response to
thrombolysis, we used an iScore cutoff of 200 to compare favorable
outcome (mRS 0–2) at discharge and risk of ICH.8
Poisson regression models were used to estimate the relative risk
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compared with their non-AF counterparts in the terciles 2 and
3 strata.
Outcomes After Thrombolytic Therapy
Overall, 1689 (13.3%) patients received thrombolysis (1373
without AF and 316 with AF). Only 40 (2.4%) patients (10 in
the non-tPA and 30 in the tPA group) received concomitant
endovascular treatment.
After adjustment, thrombolysis was associated with a favor-
able outcome (mRS 0–2) in the whole cohort (RR, 1.15; 95%
CI, 1.07–1.23) and for patients without AF (RR, 1.18; 95%
CI, 1.10–1.27). No benefit was observed for patients with AF
(RR, 0.91; 95% CI, 0.71–1.17).
There was no difference in the thrombolysis rate between
AF (46.2%) and non-AF patients (53.8%) who had an iScore
≥200. Functional status at discharge in patients with and
without AF stratified by tPA is summarized in Figure 1. In
the low iScore strata (iScore <200), AF patients had worse

(RR) of AF versus non-AF for the outcomes of interest with adjust- functional outcomes after tPA administration compared with
ment for variables in the iScore, hypertension, diabetes mellitus, hy-
non-AF patients (death or disability at discharge: 65.1%
perlipidemia, previous stroke or transient ischemic attack, dementia,
myocardial infarction, smoking, level of consciousness on arrival, non-AF versus 80.9% AF; RR, 1.24; 95% CI, 1.16–1.35). No
dysphasia, time from onset-to-treatment/admission, and arrival by difference was observed between AF and non-AF patients in
ambulance.10 We analyzed the interaction between the iScore and tPA the high iScore strata (93.5% versus 93.8%). Similar results
in the whole cohort and in patients with and without AF. were observed after excluding patients who were dependent
Statistical analysis was performed using SAS version 9.2.2 (Cary,
NC: SAS Institute Inc.). P values <0.05 were considered significant.
on admission (Supplemental Table 2).
Approvals from the St. Michael’s Hospital review board and the
RCSN Publications Committee were obtained. Table 2.  Main Outcome Measures Stratified by Terciles of the
iScore Among Patients With and Without Atrial Fibrillation
Results 30-Day Mortality
Among 12 686 patients with ischemic stroke in the RCSN
Atrial Fibrillation
sample, 2185 (17.2%) had AF. Patients with AF were more
likely older, female, and had more severe strokes compared iScore Yes, n (%) No, n (%) RR (95% CI)* P Value
with non-AF patients. Other differences in baseline charac- First tertile ≤5 (2.0) 56 (1.4) 1.45 (0.46–4.59) 0.52
teristics are summarized in Table 1. The mean iScore was (n=4222)
35 points higher among AF compared with non-AF patients Second tertile 40 (5.4) 177 (5.2) 1.03 (0.74–1.45) 0.82
(mean iScore: 164.4 [AF] versus 129.4 [non-AF]). Similar (n=4117)
differences were observed for the scoring system to estimate Third tertile 445 (34.7) 838 (28.2) 1.23 (1.12–1.35) <0.001
1-year mortality (Table 1). AF during after the initial admis- (n=4252)
sion occurred in an additional 5.8% (611/10 501) patients Total 488 (22.3) 1071 (10.2) 2.19 (1.98–2.41) <0.0001
with previously unrecognized AF. 1-Year Mortality

Clinical Outcomes in Patients With AF First tertile 7 (4.7) 202 (5.0) 0.85 (0.41–1.78) 0.87
(n=4222)
Overall, stroke patients with AF had higher short- and long-term
mortality, and death or disability at discharge (Table 2). For Second tertile 115 (15.6) 511 (15.1) 1.03 (0.85–1.24) 0.71
(n=4117)
example, there was a 2-fold higher risk of death at 30 days (RR,
2.19; 95% CI, 1.98–2.41) and at 1 year among stroke patients Third tertile 688 (53.6) 1,336 (45.0) 1.18 (1.11–1.26) <0.001
(n=4252)
with AF compared with those without AF. Moreover, AF
patients were less likely to be discharged home (RR, 0.88; 95% Total 810 (37.1) 2049 (19.5) 1.90 (1.78–2.03) <0.0001
CI, 0.81–0.95) and had longer length of stay (14.4 days versus 30-Day Mortality or Disability at Discharge
12.6 days; P<0.001) compared with their non-AF counterparts.
First tertile 54 (36.0) 1373 (33.7) 1.07 (0.86–1.33) 0.56
Outcomes Stratified by the iScore (n=4222)
Overall, for lower iScore values (terciles 1 and 2) there was Second tertile 366 (49.8) 1786 (52.8) 0.94 (0.87–1.02) 0.14
no significant difference in death or disability at discharge, (n=4117)
death at 30 days, and death at 1 year between patients with Third tertile 1,102 (85.9) 2583 (87.0) 0.99 (0.96–1.01) 0.33
and without AF. Patients with AF with a higher iScore (tercile (n=4252)
3) had higher mortality at 30 days (RR, 1.23; 95% CI, 1.12– Total 1522 (69.7) 5742 (54.7) 1.27 (1.23–1.31) <0.0001
1.35) and at 1 year (RR, 1.18; 95% CI, 1.11–1.26) (Table 2). CI indicates confidence interval; RR, relative risk.
Stroke patients with AF were less likely discharged home *See text for further details on adjustment
 102  Stroke  January 2013
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AF was associated with an increased risk of intracranial
hemorrhage (any type) (16.5% versus 11.6%; RR, 1.42; 95%
CI, 1.05–1.91) (Table 3). Similar trends were observed for
patients with symptomatic ICH (9.2% versus 6.4%; RR 1.43;
95% CI, 0.93–2.17). AF was not associated with higher risk of
ICH (symptomatic or any type) after thrombolysis when strat-
ified by the iScore (Table 3) likely attributable to the smaller
sample sizes.
Figure 2 represents the RR for a favorable outcome at
each level of the iScore stratified by AF derived from the
multivariable model in the whole cohort (n=12 686). There was
an interaction between tPA and AF (P=0.0099) and between
tPA and the iScore (P<0.0001) for a favorable outcome in
the whole cohort (P<0.0001). In the stratified analysis by AF
status, there was also an interaction between tPA and the iScore
(P<0.0012) for a favorable outcome among patients without
AF (Figure 2). A similar trend was observed in the AF subgroup
with a nonsignificant interaction (P=0.17) likely attributable
to the smaller sample size. Together, these results suggest the
iScore can predict the probability of a favorable outcome after
thrombolysis in the entire cohort, but the benefit of tPA may
decline more rapidly at lower iScore values among AF patients
(iScore 125) compared with non-AF (iScore 165) (Figure 2A).
Discussion
Patients with AF are at increased risk of stroke,2 usually asso-
ciated with poorer outcomes.1 Particularly challenging is the
prediction of a clinical response to thrombolysis considering
the diverse interaction between AF with age and other coexist-
ing comorbidities in stroke patients and the risk of hemorrhagic
Table 3.  Outcomes Among Patients Receiving tPA With and Without Atrial Fibrillation
Death at 30 Days or Disability at Discharge
Atrial Fibrillation
iScore Yes (n=316) No (n=1373) P Value
< 200 (n=1516) 191 (80.9) 833 (65.1) < 0.001
≥ 200 (n=173) 75 (93.8) 87(93.5) 0.96
Total 266 (84.2) 920 (67.0) <0.001
Numbers between parentheses represent percentages.
Figure 1.  Functional outcomes at dis-
charge (modified Rankin scale [mRS])
in patients receiving and not receiving
thrombolysis stratified by atrial fibrillation.
mRS at discharge was not available in 95
(0.7%) patients.
complications.11,12 In previous studies, our group showed the
iScore, a validated prognostic score that includes AF, predicts
clinical outcomes and response to thrombolysis.6–8
In the present study, we showed an incremental mortality at
30 days and at 1 year and a lower probability of discharge home
among patients with AF compared with patients without AF in
the same high iScore strata. AF was associated with higher
risk of death or disability and hemorrhagic complications
after thrombolysis. The trend for a clinical response to tPA
was similar between stroke patients with and without AF,
and hence we believe that the lack of a significant interaction
(Figure 2D) is likely attributable to the smaller sample size.
There are several tools available to predict clinical out-
comes or response to thrombolysis. Interestingly, AF was
not included in these scores.13–17 Our results are consistent
with previous observations showing poorer outcomes among
patients with AF receiving thrombolysis.18–22 Previous studies
also found a higher risk of symptomatic ICH after tPA among
patients with AF (odds ratio [OR], 2.95; 95% CI, 1.12–9.30).18
We found an overall similar increased risk of ICH with a
higher trend toward patients with higher iScore. Our study
also showed that AF patients had higher iScore values (AF
adds 10 points to the iScore, whereas AF patients had an aver-
age iScore 35 points greater than their non-AF counterparts).
This is explained by the additional impact of older age, more
severe strokes, and more comorbid conditions in patients with
AF (Table 1). The adverse impact of AF is likely attributable
to larger areas of hypoperfusion and lower recanalization
leading to larger infarct volumes and more severe hemor-
rhagic transformation.21,23,24
Hemorrhagic Transformation (Any Type) Symptomatic Hemorrhagic Transformation
Atrial Fibrillation Atrial Fibrillation
Yes (n=316) No (n=1373) P Value Yes (n=316) No (n=1373) P Value
33 (14.0) 134 (10.5) 0.11 19 (8.1) 72 (5.6) 0.15
19 (23.8) 25 (26.9) 0.64 10 (12.5) 16 (17.2) 0.39
52 (16.5) 159 (11.6) 0.018 29 (9.2) 88 (6.4) 0.08
 Saposnik et al   Atrial Fibrillation: The iScore, tPA, and Stroke Outcomes   103

A B

C D
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Figure 2.   Adjusted probability of a favorable outcome (modified Rankin scale [mRS] 0–2) at discharge in tPA treated patients compared
with non-tPA patients by the iScore. A, represents the probability of a favorable outcome in the whole population and patients with and
without atrial fibrillation (AF). The probability of a favorable outcome and the 95% CI is represented for the whole population (B), for
patients without AF (C), and for patients with AF (D). The horizontal line indicates the relative risk of 1 (no treatment effect). Dotted lines
represent the 95% CI. See text for further details.

The differential response to thrombolysis in patients with
AF has not been extensively studied. Most clinical trials
were not powered to explore an interaction between AF
and treatment effect.25–29 In the NINDS tPA trial, AF (n=50)
was associated with worse global outcome (OR, 0.57; 95%
CI, 0.38–0.86), but there was no significant interaction with
treatment.28 In the European Cooperative Acute Stroke Study
(ECASS) III trial, there were 53 patients with AF receiving
tPA and 55 in the placebo arm. There was a trend for higher
mortality and lower response to tPA among patients with AF.29
In the recently published IST3 study, the authors reported
no differential benefit when comparing tPA versus control
among patients with (24.1% versus 22.3%) or without (42.2%
versus 40.4%) AF.30 In the VISTA Collaboration, among 3027
patients receiving thrombolysis, 1631 (53.9%) had a history
of AF.31 The authors found a similar magnitude of benefit with
tPA compared with placebo for patients with AF (OR, 1.44;
95% CI, 1.12–1.73) and without AF (OR, 1.53; 95% CI, 1.39–
1.69). Similar to our findings (Figure 1), non-AF patients
receiving tPA had a better favorable outcome (49.3% versus
33%; OR, 0.81; 95% CI, 0.66–1.00) if the mRS is categorized
as 0 to 2 versus 3 to 6. There was no significant difference
in ICH (asymptomatic or symptomatic) between AF and
non-AF patients among tPA or controls.31 In contrast to the
VISTA results, we found a trend for a favorable outcome after
tPA among AF patients, but not reaching significance, likely
explained by the smaller tPA sample in our study.
In previous studies, we also demonstrated that the iScore
improves on the accuracy of other simple models (only
including age and stroke severity), which may underestimate
poor clinical outcomes.6 AF is highly prevalent and one of the
top risk factors for poor functional outcomes (OR, 2.51; 95%
CI, 2.17–2.91) after age and stroke severity.6,8 Moreover, the
probability of achieving a favorable outcome is lower among
patients with AF (Figure 1) and sharply declined with higher
iScore risk (Figure 2).
Our study has several limitations and strengths. First, we
were not able to evaluate imaging variables (eg, infarct size,
recanalization) known to affect clinical outcomes. However,
the intention of this study was to evaluate a differential
effect of AF on outcomes when applying a clinical score.
Second, a type II error may explain the observed trends (but
not reaching significance) after tPA in AF patients. Third,
the regression models to estimate a favorable outcome
(Figure 2) may be unstable and should be viewed as hypoth-
esis generating.
 104  Stroke  January 2013
Strengths of our study include a large sample size compris-
ing real world patients, a considerable number of individuals
with AF and patients receiving tPA, and the use of a previ-
ously validated score with a nearly complete ascertainment of
stroke severity and follow-up.
This study suggests the iScore predicts outcomes both for
patients with and without AF. Acute ischemic stroke patients
with AF have higher mortality, poorer functional outcomes,
greater risk of ICH, and a lower response to thrombolysis com-
pared with non-AF stroke patients for a given high iScore. This
is likely explained by the older age, more severe strokes, and
higher prevalence of comorbidities as reflected by an average
iScore 35 point higher in AF compared with non-AF patients.
Nevertheless, thrombolysis may still be beneficial in AF individ-
uals compared with not administering thrombolysis. The gen-
erally poor outcomes after ischemic stroke in patients with AF
reinforces the major importance of therapies aimed at primary
stroke prevention.
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Disclosures
Dr Saposnik is supported by Distinguished Clinician-Scientist Award
from the Heart and Stroke Foundation of Canada. The opinions, re-
sults, and conclusions reported in this paper are those of the authors
and are independent from the funding sources. No endorsement by
ICES or the Ontario MOHLTC is intended or should be inferred.
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 Atrial Fibrillation in Ischemic Stroke: Predicting Response to Thrombolysis and Clinical
Outcomes
Gustavo Saposnik, David Gladstone, Roula Raptis, Limei Zhou, Robert G. Hart and on behalf of
the Investigators of the Registry of the Canadian Stroke Network (RCSN) and the Stroke
Outcomes Research Canada (SORCan) Working Group
Downloaded from http://stroke.ahajournals.org/ by guest on December 4, 2017

on behalf of the Investigators of the Registry of the Canadian Stroke Network (RCSN) and the
Stroke Outcomes Research Canada (SORCan) Working Group

Stroke. 2013;44:99-104; originally published online November 20, 2012;

doi: 10.1161/STROKEAHA.112.676551
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