Is Warfarin Really a Reasonable Therapeutic Alternative to Aspirin for Preventing Recurrent Noncardioembolic Ischemic Stroke?

Eleven years ago, on June 1, 1991, Dr J.P. Mohr addressed delegates of the International Conference on Stroke, Geneva, about anticoagulants as a therapeutic strategy in stroke. He bemoaned the fact that heparin and warfarin had the “bad luck” to be manufactured initially in the post–World War II period, before drugs were evaluated by controlled clinical trials. As a consequence, clinicians judged their effectiveness on the basis of theory and compared their personal experience with historical controls and with those found in the literature. With the passage of time, the drug patents expired, the views and practices of clinicians became polarized, and any commercial and scientific motive to conduct controlled clinical trials of anticoagulation in secondary stroke prevention, once called for, disappeared. Dr Mohr sadly concluded that “there are no [reliable] data really” for anticoagulation after ischemic stroke. This was probably the platform from which he planned, with colleagues, the Warfarin-Aspirin Recurrent Stroke Study (WARSS).1