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Meschia JF. William M. Feinberg Lecture: Asymptomatic Carotid Stenosis: Current and Future Considerations. Stroke 2024; 55:2184-2192. [PMID: 38920049 PMCID: PMC11331494 DOI: 10.1161/strokeaha.124.046956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
Asymptomatic high-grade carotid stenosis is an important therapeutic target for stroke prevention. For decades, the ACAS (Asymptomatic Carotid Atherosclerosis Study) and ACST (Asymptomatic Carotid Surgery Trial) trials provided most of the evidence supporting endarterectomy for patients with asymptomatic high-grade stenosis who were otherwise good candidates for surgery. Since then, transfemoral/transradial carotid stenting and transcarotid artery revascularization have emerged as alternatives to endarterectomy for revascularization. Advances in treatments against atherosclerosis have driven down the rates of stroke in patients managed without revascularization. SPACE-2 (Stent-Protected Angioplasty Versus Carotid Endarterectomy-2), a trial that included endarterectomy, stenting, and medical arms, failed to detect significant differences in stroke rates among treatment groups, but the study was stopped well short of its recruitment goal. CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will be able to clarify whether revascularization by stenting or endarterectomy remains efficacious under conditions of intensive medical management. Transcarotid artery revascularization has a favorable periprocedural risk profile, but randomized trials comparing it to intensive medical management are lacking. Features like intraplaque hemorrhage on MRI and echolucency on B-mode ultrasonography can identify patients at higher risk of stroke with asymptomatic stenosis. High-grade stenosis with poor collaterals can cause hemispheric hypoperfusion, and unstable plaque can cause microemboli, both of which may be treatable risk factors for cognitive impairment. Evidence that there are patients with carotid stenosis who benefit cognitively from revascularization is presently lacking. New risk factors are emerging, like exposure to microplastics and nanoplastics. Strategies to limit exposure will be important without specific medical therapies.
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Affiliation(s)
- James F Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL
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2
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Baker D, Cruddas L, Eveson T, Bakhai A, Penge J. Patient Acceptance and Adherence to the COMPASS Trial Drug Recommendations Following Symptomatic Carotid Endarterectomy. Ann Vasc Surg 2024; 108:403-409. [PMID: 39009129 DOI: 10.1016/j.avsg.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The COMPASS trial demonstrated that in patients with atherosclerotic diseases, low-dose rivaroxaban and aspirin provides greater protection against subsequent major adverse cardiovascular events (MACEs) than mono-antiplatelet therapy (MAPT) alone. Drug acceptance and adherence maximizes this benefit. We have assessed drug acceptance and adherence to the COMPASS drug regime in patients following carotid endarterectomy (CEA) for symptomatic carotid artery stenosis. METHODS Following CEA, the views of 63 patients on the COMPASS drug regime were assessed using the Beliefs about Medicine Questionnaire and drug adherence was determined using the Sidorkiewicz scoring system. These views were compared with those of 54 patients on MAPT. Side effects (bleeding and drug reactions) and new MACE were recorded. RESULTS Post-CEA patients on the COMPASS drug regimen had strong positive views on the necessity to take these drugs (necessity scale 19.6 ± 3.6). Although there were some concerns about the COMPASS drug regimen, these were not strongly held (concern cscale 11.8 ± 4.9) and the necessity-concerns differential was positive (7.8 ± 6.2). The Drug Adherence Score was "High" to "Good" (level of drug adherence 1.7 ± 1.0). The Beliefs about Medicine Questionnaire scales and Drug Adherence Score of post-CEA patients on the COMPASS drug regimen were similar to those on MAPT. The incidence of post-CEA MACE and side effects were similar for those on the COMPASS drug regimen and MAPT. CONCLUSIONS Post-CEA patients on the COMPASS drug regimen had positive views on taking the drugs and drug adherence was high. We did not identify any patient-related barriers to the use of the COMPASS drug regimen to further reduce cardiovascular events.
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Affiliation(s)
- Daryll Baker
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK; Vascular Surgery Service, The National Hospital for Neurology and, Neurosurgery, University College Hospitals NHS Foundation Trust, London, UK; UCL Division of Medicine, Royal Free Campus, University College London, London, UK.
| | - Lucinda Cruddas
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK; UCL Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Tom Eveson
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK
| | - Ameet Bakhai
- UCL Division of Medicine, Royal Free Campus, University College London, London, UK; Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
| | - Justin Penge
- UCL Division of Medicine, Royal Free Campus, University College London, London, UK; Department of Stroke Medicine, Royal Free London NHS Foundation Trust, London, UK
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3
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Li B, Shaikh F, Zamzam A, Abdin R, Qadura M. Inflammatory Biomarkers to Predict Major Adverse Cardiovascular Events in Patients with Carotid Artery Stenosis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:997. [PMID: 38929614 PMCID: PMC11205582 DOI: 10.3390/medicina60060997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Inflammatory proteins and their prognostic value in patients with carotid artery stenosis (CAS) have not been adequately studied. Herein, we identified CAS-specific biomarkers from a large pool of inflammatory proteins and assessed the ability of these biomarkers to predict adverse events in individuals with CAS. Materials and Methods: Samples of blood were prospectively obtained from 336 individuals (290 with CAS and 46 without CAS). Plasma concentrations of 29 inflammatory proteins were determined at recruitment, and the patients were followed for 24 months. The outcome of interest was a major adverse cardiovascular event (MACE; composite of stroke, myocardial infarction, or death). The differences in plasma protein concentrations between patients with vs. without a 2-year MACE were determined using the independent t-test or Mann-Whitney U test to identify CAS-specific prognostic biomarkers. Kaplan-Meier and Cox proportional hazards analyses with adjustment for baseline demographic and clinical characteristics were performed to assess the prognostic value of differentially expressed inflammatory proteins in predicting a 2-year MACE in patients with CAS. Results: The mean age of the cohort was 68.8 (SD 10.2) years and 39% were female. The plasma concentrations of two inflammatory proteins were significantly higher in individuals with a 2-year MACE relative to those without a 2-year MACE: IL-6 (5.07 (SD 4.66) vs. 3.36 (SD 4.04) pg/mL, p = 0.03) and CD163 (233.825 (SD 230.306) vs. 159.673 (SD 175.669) pg/mL, p = 0.033). Over a follow-up period of 2 years, individuals with elevated levels of IL-6 were more likely to develop MACE (HR 1.269 (95% CI 1.122-1.639), p = 0.042). Similarly, over a 2-year period, patients with high levels of CD163 were more likely to develop MACE (HR 1.413 (95% CI 1.022-1.954), p = 0.036). Conclusions: The plasma levels of inflammatory proteins IL-6 and CD163 are independently associated with adverse outcomes in individuals with CAS. These CAS-specific prognostic biomarkers may assist in the risk stratification of patients at an elevated risk of a MACE and subsequently guide further vascular evaluation, specialist referrals, and aggressive medical/surgical management, thereby improving outcomes for patients with CAS.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Division of Vascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada; (F.S.); (A.Z.)
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Farah Shaikh
- Division of Vascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada; (F.S.); (A.Z.)
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada; (F.S.); (A.Z.)
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Mohammad Qadura
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Division of Vascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada; (F.S.); (A.Z.)
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Sun L, Wu G, Zhou Y, Deng A, Chen Z. Prospective study on ultrasound-guided stellate ganglion block improves cerebral blood flow in patients with stroke. J Stroke Cerebrovasc Dis 2024; 33:107593. [PMID: 38290686 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVES The effect of routine internal medicine and stroke rehabilitation treatment was not good. To confirm that ultrasound-guided stellate ganglion block (SGB) can improve cerebral blood flow in patients with stroke, Transcranial Doppler (TCD) and carotid ultrasound were used to monitor the cerebral blood flow parameters of ultrasound-guided SGB in patients with stroke. METHODS A prospective study of 40 patients with stroke from January 2021 to October 2022 randomly divided into two groups (group SGB: undergoing ultrasound-guided SGB and standard medical procedures, control group: undergoing standard medical procedures) with 20 cases in each was conducted in People's Hospital of Chongqing Liang Jiang New Area. TCD and carotid artery ultrasound were monitored before and after treatment. There were no significant differences in general data on age, gender, disease course, and stroke type between two groups (P>0.05). RESULTS After treatment, the bilateral ACA Vm of group SGB was significantly higher, the bilateral internal carotid artery RI and left VA RI were significantly lower than in control group (P<0.05). In group SGB, the Vm of bilateral MCA, bilateral PCA, right ACA, bilateral VA, and BA after treatment were significantly (P<0.05) increased compared to before treatment. PI of bilateral MCA, right ACA, and left VA after treatment were significantly (P<0.05) decreased compared to before treatment. RI of bilateral MCA, bilateral PCA, and bilateral VA after treatment were significantly (P<0.05) decreased compared to before treatment. Right internal carotid artery D after treatment was significantly (P<0.05) higher than before treatment. RI of bilateral internal carotid artery after treatment was significantly (P<0.05) lower than before treatment. CONCLUSIONS Ultrasound-guided stellate ganglion block could improve local cerebral blood flow and vascular compliance in patients with stroke, and reduce vascular resistance.
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Affiliation(s)
- Lin Sun
- Department of anesthesiology and pain, People's Hospital of Chongqing Liang Jiang New Area; Liangjiang New Area Chongqing 401121, China
| | - Gu Wu
- Department of anesthesiology and pain, People's Hospital of Chongqing Liang Jiang New Area; Liangjiang New Area Chongqing 401121, China
| | - Yuan Zhou
- Department of anesthesiology and pain, People's Hospital of Chongqing Liang Jiang New Area; Liangjiang New Area Chongqing 401121, China
| | - Ansong Deng
- Department of anesthesiology and pain, People's Hospital of Chongqing Liang Jiang New Area; Liangjiang New Area Chongqing 401121, China
| | - Zongjie Chen
- Department of anesthesiology and pain, People's Hospital of Chongqing Liang Jiang New Area; Liangjiang New Area Chongqing 401121, China.
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Ortega-Paz L, Franchi F, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Jennings LK, Angiolillo DJ. Switching from Dual Antiplatelet Therapy with Aspirin Plus a P2Y12 Inhibitor to Dual Pathway Inhibition with Aspirin Plus Vascular-Dose Rivaroxaban: The Switching Anti-Platelet and Anti-Coagulant Therapy (SWAP-AC) Study. Thromb Haemost 2024; 124:263-273. [PMID: 37224883 DOI: 10.1055/a-2098-6639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND To date, there are no data on switching to dual pathway inhibition (DPI) patients who have completed a guideline-recommended dual antiplatelet therapy (DAPT) regimen. OBJECTIVES To assess the feasibility of switching from DAPT to DPI and to compare the pharmacodynamic (PD) profiles of these treatments. METHODS This was a prospective, randomized, PD study conducted in 90 patients with chronic coronary syndrome (CCS) on DAPT with aspirin (81 mg/qd) plus a P2Y12 inhibitor (clopidogrel [75 mg/qd; n = 30], ticagrelor [90 mg/bid; n = 30], or prasugrel [10 mg/qd; n = 30]). Patients in each cohort were randomized to maintain DAPT or switch to DPI (aspirin 81 mg/qd plus rivaroxaban 2.5 mg/bid). PD assessments included: VerifyNow P2Y12 reaction units; light transmittance aggregometry following stimuli with adenosine diphosphate (ADP), tissue factor (TF), and a combination of collagen, ADP, and TF (maximum platelet aggregation %); thrombin generation (TG). Assays were performed at baseline and 30 days postrandomization. RESULTS Switching from DAPT to DPI occurred without major side effects. DAPT was associated with enhanced P2Y12 inhibition, while DPI with reduced TG. Platelet-mediated global thrombogenicity (primary endpoint) showed no differences between DAPT and DPI in the ticagrelor (14.5% [0.0-63.0] vs. 20.0% [0.0-70.0]; p = 0.477) and prasugrel (20.0% [0.0-66.0] vs. 4.0% [0.0-70.0]; p = 0.482), but not clopidogrel (27.0% [0.0-68.0] vs. 53.0% [0.0-81.0]; p = 0.011), cohorts. CONCLUSION In patients with CCS, switching from different DAPT regimens to DPI was feasible, showing enhanced P2Y12 inhibition with DAPT and reduced TG with DPI, with no differences in platelet-mediated global thrombogenicity between DPI and ticagrelor- and prasugrel-, but not clopidogrel-, based DAPT. CLINICAL TRIAL REGISTRATION http://www. CLINICALTRIALS gov Unique Identifier: NCT04006288.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
- Departmet of Cardiology, Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | | | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Virk GS, Javed S, Chaudhry R, Moazam MM, Mahmood A, Mahmood F, Zaheer M, Khan SM, Rajasekaran V. Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis. Cureus 2024; 16:e54252. [PMID: 38496142 PMCID: PMC10944328 DOI: 10.7759/cureus.54252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.
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Affiliation(s)
- Ghazala S Virk
- Internal Medicine, Avalon University School of Medicine, Ohio, USA
| | - Sana Javed
- Medicine, University of Birmingham, Royal College of General Practitioners, Birmingham, GBR
| | | | - Mustafa M Moazam
- Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Arhum Mahmood
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | - Faraz Mahmood
- Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, USA
| | - Mohammed Zaheer
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Shahroz M Khan
- Medicine, Kansas Health Science Center (KHSC) College of Osteopathic Medicine, Wichita, USA
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Popat A, Patel SK, Adusumilli S, Irshad A, Nagaraj A, Patel KK, Jani SY, Nawaz G, Wahab A, Bora S, Mittal L, Yadav S. Efficacy and Safety of Different Dosing Regimens of Rivaroxaban in Patients With Atrial Fibrillation for Stroke Prevention: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51541. [PMID: 38313978 PMCID: PMC10834223 DOI: 10.7759/cureus.51541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/06/2024] Open
Abstract
Atrial fibrillation (AF) poses a substantial risk of stroke, necessitating effective anticoagulation therapy. This systematic review and meta-analysis (SRMA) evaluates the efficacy and safety of different dosing regimens of rivaroxaban in patients with AF. A comprehensive search of relevant databases, focusing on studies published from 2017 onward, was conducted. Inclusion criteria comprised randomized controlled trials (RCTs) and observational studies comparing standard and reduced dosing of rivaroxaban in AF. Data extraction and risk of bias (ROB) assessment were performed, and a meta-analysis was conducted for relevant outcomes. A total of 21 studies fulfilled the inclusion criteria. Standard dosing demonstrates a slightly lower risk of composite effectiveness outcomes and safety outcomes (HR: 0.79, 95% CI: 0.66-0.94, P=0.01) compared to reduced dosing (HR: 0.83, 95% CI: 0.71-0.97, P=0.02). Notable differences in major bleeding, gastrointestinal bleeding (GIB), and intracranial bleeding favored standard dosing. Hemorrhagic stroke and all-cause stroke rates differed significantly, with standard dosing showing a more favorable profile for ischemic stroke prevention. This study highlights the pivotal role of personalized anticoagulation therapy in AF. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines. The study bridges evidence from clinical trials to real-world practice, offering insights into the evolving landscape of AF management.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | | | - Ahmed Irshad
- Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
| | - Aishwarya Nagaraj
- Surgery and Pharmacology, Our Lady of Fatima University, Bangalore, IND
| | - Krisha K Patel
- College of Medicine, Dr. M. K. Shah Medical College and Research Center, Ahmedabad, IND
| | - Stavan Y Jani
- Internal Medicine, Bukovinian State Medical University, Chernivtsi, UKR
| | - Gul Nawaz
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | - Abdul Wahab
- Internal Medicine, Sargodha Medical College, Sargodha, PAK
| | - Satya Bora
- Neurology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Ahmedabad, IND
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9
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Cui Y, Yuan ZM, Liu QY, Wang YJ, Chen HS. Remote Ischemic Conditioning and Outcomes in Acute Ischemic Stroke With Versus Without Large Artery Atherosclerosis. Stroke 2023; 54:3165-3168. [PMID: 37850359 DOI: 10.1161/strokeaha.123.045040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/22/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND RICAMIS trial (The Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke) has demonstrated efficacy of remote ischemic conditioning (RIC) in acute ischemic stroke. We conducted a post hoc analysis of RICAMIS to investigate whether large artery atherosclerosis (LAA) subtype contributed to the outcomes. METHODS This is a post hoc analysis of the RICAMIS trial. Patients randomized to RIC group and Control group in full analysis set of RICAMIS were classified into LAA and non-LAA subtypes. The primary outcome was excellent functional outcome at 90 days, defined as modified Rankin Scale score of 0 to 1. Compared with patients receiving usual care, we investigated the association of RIC effect with outcomes in stroke subtypes and the interaction between RIC effect and stroke subtypes. The primary analysis was adjusted analysis. RESULTS Among 1773 patients, 516 were assigned to LAA subtype (229 in the RIC group and 287 in the control group) and 1257 to non-LAA subtype (633 in the RIC group and 624 in the control group). Median age was 65 years, and 34.2% were women. A higher proportion of primary outcome was found to be associated with RIC treatment in LAA subtype (adjusted risk difference, 11.4% [95% CI, 3.6%-19.2%]; P=0.004), but not in non-LAA subtype (adjusted risk difference, 4.1% [95% CI, -1.1% to 9.3%]; P=0.12). There was no significant interaction between RIC effect and stroke subtypes (P=0.12). CONCLUSIONS Patients with LAA subtype may benefit from RIC after stroke with respect to excellent functional outcome at 90 days. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03740971.
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Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Zhi-Mei Yuan
- Department of Neurology, Tonghua Vascular Disease Hospital (Dongchang District People's Hospital), Tonghua, China (Z.-M.Y.)
| | - Quan-Ying Liu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Ying-Jia Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
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10
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Maloberti A, Intravaia RCM, Mancusi C, Cesaro A, Golia E, Ilaria F, Coletta S, Merlini P, De Chiara B, Bernasconi D, Algeri M, Ossola P, Ciampi C, Riccio A, Tognola C, Ardissino M, Inglese E, Scaglione F, Calabrò P, De Luca N, Giannattasio C. Secondary Prevention and Extreme Cardiovascular Risk Evaluation (SEVERE-1), Focus on Prevalence and Associated Risk Factors: The Study Protocol. High Blood Press Cardiovasc Prev 2023; 30:573-583. [PMID: 38030852 PMCID: PMC10721661 DOI: 10.1007/s40292-023-00607-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Despite significant improvement in secondary CardioVascular (CV) preventive strategies, some acute and chronic coronary syndrome (ACS and CCS) patients will suffer recurrent events (also called "extreme CV risk"). Recently new biochemical markers, such as uric acid (UA), lipoprotein A [Lp(a)] and several markers of inflammation, have been described to be associated with CV events recurrence. The SEcondary preVention and Extreme cardiovascular Risk Evaluation (SEVERE-1) study will accurately characterize extreme CV risk patients enrolled in cardiac rehabilitation (CR) programs. AIM Our aims will be to describe the prevalence of extreme CV risk and its association with newly described biochemical CV risk factors. AIM Our aims will be to describe the prevalence of extreme CV risk and its association with newly described biochemical CV risk factors. METHODS We will prospectively enrol 730 ACS/CCS patients at the beginning of a CR program. Extreme CV risk will be retrospectively defined as the presence of a previous (within 2 years) CV events in the patients' clinical history. UA, Lp(a) and inflammatory markers (interleukin-6 and -18, tumor necrosis factor alpha, C-reactive protein, calprotectin and osteoprotegerin) will be assessed in ACS/CCS patients with extreme CV risk and compared with those without extreme CV risk but also with two control groups: 1180 hypertensives and 765 healthy subjects. The association between these biomarkers and extreme CV risk will be assessed with a multivariable model and two scoring systems will be created for an accurate identification of extreme CV risk patients. The first one will use only clinical variables while the second one will introduce the biochemical markers. Finally, by exome sequencing we will both evaluate polygenic risk score ability to predict recurrent events and perform mendellian randomization analysis on CV biomarkers. CONCLUSIONS Our study proposal was granted by the European Union PNRR M6/C2 call. With this study we will give definitive data on extreme CV risk prevalence rising attention on this condition and leading cardiologist to do a better diagnosis and to carry out a more intensive treatment optimization that will finally leads to a reduction of future ACS recurrence. This will be even more important for cardiologists working in CR that is a very important place for CV risk definition and therapies refinement.
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Affiliation(s)
- Alessandro Maloberti
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy.
| | | | - Costantino Mancusi
- Cardiac Rehabilitation Unit, Federico II° University Hospital, Naples, Italy
| | | | - Enrica Golia
- S. Anna e S. Sebastiano Hospital, Caserta, Italy
| | - Fucile Ilaria
- Cardiac Rehabilitation Unit, Federico II° University Hospital, Naples, Italy
| | | | - Piera Merlini
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy
| | - Benedetta De Chiara
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy
| | - Davide Bernasconi
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Clinical Research and Innovation, Niguarda Hospital, Milan, Italy
| | - Michela Algeri
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy
| | - Paolo Ossola
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Claudio Ciampi
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Alfonso Riccio
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Chiara Tognola
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy
| | - Maddalena Ardissino
- Cambridge University Hospitals NHS Trust, Cambridge, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Elvira Inglese
- Department of Laboratory Medicine, ASST "Grande Ospedale Metropolitano" Niguarda, 20162, Milan, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, 27100, Pavia, Italy
| | - Francesco Scaglione
- Department of Laboratory Medicine, ASST "Grande Ospedale Metropolitano" Niguarda, 20162, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | | | - Nicola De Luca
- Cardiac Rehabilitation Unit, Federico II° University Hospital, Naples, Italy
| | - Cristina Giannattasio
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Cardiology 4, Cardio Center, ASST GOM Niguarda, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20159, Milan, Italy
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11
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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12
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Caliandro P, Cancelloni V, Marco M, Reale G, Zauli A, Agnelli G, Caso V, Becattini C, Calabresi P, Giulia Mosconi M, Giustozzi M, Tsivgoulis G, Julian Seiffge D, Engelter ST, Lyrer P, Polymeris AA, Dittrich T, Zietz A, Marco De Marchis G, Putaala J, Strbian D, Tomppo L, Michel P, Strambo D, Salerno A, Remillard S, Buehrer M, Bavaud O, Vanacker P, Zuurbier S, Yperzeele L, Loos CM, Cappellari M, Emiliani A, Zedde M, Abdul-Rahim A, Dawson J, Cronshaw R, Schirinzi E, Del Sette M, Stretz C, Kala N, Reznik M, Schomer A, Mac Grory B, Jayaraman M, McTaggart R, Yaghi S, Furie KL, Masotti L, Grifoni E, Toni D, Risitano A, Falcou A, Petraglia L, Maria Lotti E, Padroni M, Pavolucci L, Lochner P, Silvestrelli G, Ciccone A, Alberti A, Venti M, Leone De Magistris I, Kargiotis O, Rocco A, Diomedi M, Marcheselli S, Antonenko K, Rota E, Tassinari T, Saia V, Palmerini F, Aridon P, Arnao V, Monaco S, Cottone S, Baldi A, D’Amore C, Ageno W, Pegoraro S, Ntaios G, Sagris D, Giannopoulos S, Kosmidou M, Ntais E, Romoli M, Pantoni L, Rosa S, Bertora P, Chiti A, Canavero I, Emanuele Saggese C, Plocco M, Giorli E, Palaiodimou L, Bakola E, Bandini F, Gasparro A, Terruso V, Mannino M, Pezzini A, Ornello R, Sacco S, Popovic N, Scoditti U, Genovese A, Denti L, Flomin Y, Mancuso M, Ferrari E, Chiara Caselli M, Ulivi L, Giannini N, Vadikolias K, Liantinioti C, Chondrogianni M, Halvatsiotis P, Carletti M, Karagkiozi E, Athanasakis G, Makaritsis K, Lanari A, Tatlisumak T, Acciarresi M, Vannucchi V, Lorenzini G, Tassi R, Guideri F, Acampa M, Martini G, Sohn SI, Mumoli N, Tadi P, Letteri F, Maccarrone M, Poli L, Magoni M, Galati F, Tiseo C, Gourbali V, Orlandi G, Giuntini M, Corea F, Bellesini M, Girardi L, Maimone Baronello M, Karapanayiotides T, Rueckert C, Csiba L, Szabó L, Rigatelli A, Imberti D, Zabzuni D, Pieroni A, Barlinn K, Pallesen LP, Barlinn J, Doronin B, Volodina V, Deleu D, Bonetti B, Porta C, Gentile L, Eskandari A, Paciaroni M. Risk of recurrent stroke in patients with atrial fibrillation treated with oral anticoagulants alone or in combination with anti-platelet therapy. Eur Stroke J 2023; 8:722-730. [PMID: 37458099 PMCID: PMC10472945 DOI: 10.1177/23969873231183211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. PATIENTS AND METHODS We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). RESULTS During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01-1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48-3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02-2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19-3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01-1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06-4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23-4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35-2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45-2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06-3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05-2.74]). DISCUSSION Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. CONCLUSION Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.
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Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Ananth CV, Brandt JS, Keyes KM, Graham HL, Kostis JB, Kostis WJ. Epidemiology and trends in stroke mortality in the USA, 1975-2019. Int J Epidemiol 2023; 52:858-866. [PMID: 36343092 PMCID: PMC10244057 DOI: 10.1093/ije/dyac210] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/18/2022] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Whether changes in stroke mortality are affected by age distribution and birth cohorts, and if the decline in stroke mortality exhibits heterogeneity by stroke type, remains uncertain. METHODS We undertook a sequential time series analysis to examine stroke mortality trends in the USA among people aged 18-84 years between 1975 and 2019 (n = 4 332 220). Trends were examined for overall stroke and by ischaemic and haemorrhagic subtypes. Mortality data were extracted from the US death files, and age-sex population data were extracted from US census. Age-standardized stroke mortality rates and incidence rate ratio (IRR) with 95% confidence interval [CI] were derived from Poisson regression models. RESULTS Age-standardized stroke mortality declined for females from 87.5 in 1975 to 30.9 per 100 000 in 2019 (IRR 0.27, 95% CI 0.26, 0.27; average annual decline -2.78%, 95% CI -2.79, -2.78). Among males, age-standardized mortality rate declined from 112.1 in 1975 to 38.7 per 100 000 in 2019 (RR 0.26, 95% CI 0.26, 0.27; average annual decline -2.80%, 95% CI -2.81, -2.79). Stroke mortality increased sharply with advancing age. Decline in stroke mortality was steeper for ischaemic than haemorrhagic strokes. CONCLUSIONS Stroke mortality rates have substantially declined, more so for ischaemic than haemorrhagic strokes.
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Affiliation(s)
- Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Katherine M Keyes
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Hillary L Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John B Kostis
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - William J Kostis
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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15
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Tao L, Wang YH, Shang ZY, Yang BQ, Chen HS. Vulnerable plaque of the petrous internal carotid artery in embolic stroke of undetermined source. Eur J Neurol 2023; 30:648-658. [PMID: 36448742 DOI: 10.1111/ene.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND PURPOSE The association between nonstenotic plaque at the petrous internal carotid artery (ICA) and embolic stroke of undetermined source (ESUS) remains unknown. We aimed to test the hypothesis that the presence of a larger build-up of petrous plaque is more prevalent in the ipsilateral versus the contralateral side among ESUS patients without plaque in the intracranial and proximal ICA. METHODS From a total of 243 patients with ESUS and 160 patients with small-vessel disease (SVD) without proximal ICA plaque, we enrolled 88 ESUS and 103 SVD patients without ipsilateral nonstenotic intracranial and proximal ICA plaque in the present study. Targeting the petrous segment of the ICA on two sides, plaque burden including plaque thickness, lumen area, vessel area, wall area, and percentage of luminal stenosis, and composition features (presence/absence of the ruptured fibrous cap, ulcer plaque, thrombus, discontinuity of plaque surface [DPS], intraplaque hemorrhage and complicated plaque) were assessed by high-resolution magnetic resonance imaging. RESULTS We found a higher prevalence of petrous plaque thickness ≥3.5 mm ipsilateral versus contralateral to the stroke (25/88 [28.4%] vs. 12/88 [13.6%], odds ratio [OR] 3.60, 95% confidence interval [CI] 1.34-9.70), but this imbalance was not seen in SVD. In patients with plaque thickness ≥3.5 mm, the presence of DPS (OR 4.05, 95% CI 1.11-14.78) and complicated plaque (OR 5.00, 95% CI 1.10-22.82) was more closely related to an index ESUS, a finding that was not evident in the subgroup with petrous plaque <3.5 mm (p for interaction = 0.027). CONCLUSIONS The present study provided the first evidence supporting a potential etiological role of vulnerable petrous plaque in ESUS.
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Affiliation(s)
- Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Yi-Han Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Ben-Qiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
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Maximiliano CL, Jaime GC, Erika MH. Rivaroxaban plus aspirin versus acenocoumarol to manage recurrent venous thromboembolic events despite systemic anticoagulation with rivaroxaban. Thromb Res 2023; 222:43-48. [PMID: 36565679 DOI: 10.1016/j.thromres.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The evaluation and management of patients who sustain recurrent thromboembolic events while taking therapeutic anticoagulation have not been well characterized; moreover, there has been no systematic review or randomized trial focused on treating patients with recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) during anticoagulant treatment. Therefore, we developed a pilot trial to compare rivaroxaban plus aspirin versus acenocoumarol in patients with recurrent venous thromboembolism despite ongoing anticoagulation with rivaroxaban. MATERIALS AND METHODS The study was a multicenter, randomized clinical trial. We randomly assigned patients with objectively documented recurrent venous thromboembolism to receive rivaroxaban (20 mg once a day) plus aspirin (300 mg once a day) or an adjusted dose of acenocoumarol. The study was designed to evaluate the incidence of recurrent thromboembolic events (recurrent ipsilateral or contralateral DVT, PE, ischemic stroke, and myocardial infarction) and hemorrhagic events. RESULTS A total of 58 patients were randomized: 28 were allocated to the rivaroxaban plus aspirin group and 30 to the acenocoumarol group. After 90 days of follow-up, three recurrent thromboembolic events (primary outcome) occurred in the acenocoumarol group - two DVTs and one ischemic stroke - and zero events in the rivaroxaban plus aspirin group (risk ratio [RR] 0.15; 95 % confidence interval [CI] 0.008-2.83; P = 0.20). Minor bleeding occurred in five patients in the acenocoumarol group and zero in the rivaroxaban plus aspirin group (RR 0.09; 95 % CI 0.005-1.68; p = 0.10). There was one non-fatal gastrointestinal major bleed in the rivaroxaban plus aspirin group. CONCLUSIONS In this pilot study, there were no significant differences in any outcome assessed; however, recurrent thromboembolic events and minor bleeding events occurred numerically less frequently in the rivaroxaban plus aspirin group. These data suggest the need to carry out more extensive randomized studies with sufficient statistical power to clarify these results.
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Affiliation(s)
- Correa Lara Maximiliano
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico; Environmental Toxicology Laboratory, Instituto Politécnico Nacional, Mexico.
| | - García Chavez Jaime
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Are Factor Xa Inhibitors Efficacious for Ischemic Stroke Prevention in Patients Without Atrial Fibrillation? Evidence From Randomized Clinical Trials. Can J Cardiol 2023; 39:187-197. [PMID: 36179950 DOI: 10.1016/j.cjca.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinical trials provide conflicting evidence regarding oral factor Xa inhibitors for prevention of ischemic stroke in patients without a history of atrial fibrillation (AF). METHODS We performed a critical appraisal of randomized clinical trials that tested oral factor Xa inhibitors in patients without AF that reported ischemic stroke. RESULTS Considering the 11 trials that reported > 10 ischemic strokes during follow-up (97,578 participants, 1195 ischemic strokes), 1 tested apixaban (57 strokes), 1 betrixaban (52 strokes), and 9 rivaroxaban (1086 strokes). In 7 trials with placebo comparisons, numerically fewer ischemic strokes occurred among those assigned factor Xa inhibitors in 7 of 8 randomized comparisons (range of hazard ratios [HRs], 0.89-0.51), including statistically significant reductions in 2 trials that compared rivaroxaban 2.5 mg twice daily vs placebo on a background of aspirin in patients with cardiovascular disease, COMPASS (HR, 0.51; 95% confidence interval [CI], 0.38-0.68) and COMMANDER-HF (HR, 0.64; 95% CI, 0.43-0.95). Compared with aspirin in 4 trials, oral factor Xa inhibitors were associated with fewer ischemic strokes in 2, with statistically significant reduction in 1 (rivaroxaban 5 mg twice daily in COMPASS; HR, 0.69; 95% CI, 0.53-0.90). Major bleeding was increased by oral factor Xa inhibitors in all 7 placebo-controlled trials (HR range, 1.42-4.08), with statistically significant increases reported in 5 trials, and in all 4 aspirin-controlled trials (all statistically significant increases; HR range, 1.52-2.72). CONCLUSIONS Aggregate evidence on the basis of placebo comparisons from randomized trials supports the potential for oral factor Xa inhibitors to reduce ischemic stroke in patients without AF, but major bleeding is increased.
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Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
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Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Shoamanesh A, Mundl H, Smith EE, Masjuan J, Milanov I, Hirano T, Agafina A, Campbell B, Caso V, Mas JL, Dong Q, Turcani P, Christensen H, Ferro JM, Veltkamp R, Mikulik R, De Marchis GM, Robinson T, Lemmens R, Stepien A, Greisenegger S, Roine R, Csiba L, Khatri P, Coutinho J, Lindgren AG, Demchuk AM, Colorado P, Kirsch B, Neumann C, Heenan L, Xu L, Connolly SJ, Hart RG. Factor XIa inhibition with asundexian after acute non-cardioembolic ischaemic stroke (PACIFIC-Stroke): an international, randomised, double-blind, placebo-controlled, phase 2b trial. Lancet 2022; 400:997-1007. [PMID: 36063821 DOI: 10.1016/s0140-6736(22)01588-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Asundexian (Bayer AG, Leverkusen, Germany), an oral small molecule factor XIa (FXIa) inhibitor, might prevent thrombosis without increasing bleeding. Asundexian's effect for secondary prevention of recurrent stroke is unknown. METHODS In this randomised, double-blind, placebo-controlled, phase 2b dose-finding trial (PACIFIC-Stroke), patients with acute (within 48 h) non-cardioembolic ischaemic stroke were recruited from 196 hospitals in 23 countries. Patients were eligible if they were aged 45 years or older, to be treated with antiplatelet therapy, and able to have a baseline MRI (either before or within 72 h of randomisation). Eligible participants were randomly assigned (1:1:1:1), using an interactive web-based response system and stratified according to anticipated antiplatelet therapy (single vs dual), to once daily oral asundexian (BAY 2433334) 10 mg, 20 mg, or 50 mg, or placebo in addition to usual antiplatelet therapy, and were followed up during treatment for 26-52 weeks. Brain MRIs were obtained at study entry and at 26 weeks or as soon as possible after treatment discontinuation. The primary efficacy outcome was the dose-response effect on the composite of incident MRI-detected covert brain infarcts and recurrent symptomatic ischaemic stroke at or before 26 weeks after randomisation. The primary safety outcome was major or clinically relevant non-major bleeding as defined by International Society on Thrombosis and Haemostasis criteria. The efficacy outcome was assessed in all participants assigned to treatment, and the safety outcome was assessed in all participants who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT04304508, and is now complete. FINDINGS Between June 15, 2020, and July 22, 2021, 1880 patients were screened and 1808 participants were randomly assigned to asundexian 10 mg (n=455), 20 mg (n=450), or 50 mg (n=447), or placebo (n=456). Mean age was 67 years (SD 10) and 615 (34%) participants were women, 1193 (66%) were men, 1505 (83%) were White, and 268 (15%) were Asian. The mean time from index stroke to randomisation was 36 h (SD 10) and median baseline National Institutes of Health Stroke Scale score was 2·0 (IQR 1·0-4·0). 783 (43%) participants received dual antiplatelet treatment for a mean duration of 70·1 days (SD 113·4) after randomisation. At 26 weeks, the primary efficacy outcome was observed in 87 (19%) of 456 participants in the placebo group versus 86 (19%) of 455 in the asundexian 10 mg group (crude incidence ratio 0·99 [90% CI 0·79-1·24]), 99 (22%) of 450 in the asundexian 20 mg group (1·15 [0·93-1·43]), and 90 (20%) of 447 in the asundexian 50 mg group (1·06 [0·85-1·32]; t statistic -0·68; p=0·80). The primary safety outcome was observed in 11 (2%) of 452 participants in the placebo group versus 19 (4%) of 445 in the asundexian 10 mg group, 14 (3%) of 446 in the asundexian 20 mg group, and 19 (4%) of 443 in the asundexian 50 mg group (all asundexian doses pooled vs placebo hazard ratio 1·57 [90% CI 0·91-2·71]). INTERPRETATION In this phase 2b trial, FXIa inhibition with asundexian did not reduce the composite of covert brain infarction or ischaemic stroke and did not increase the composite of major or clinically relevant non-major bleeding compared with placebo in patients with acute, non-cardioembolic ischaemic stroke. FUNDING Bayer AG.
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Affiliation(s)
- Ashkan Shoamanesh
- Division of Neurology, McMaster University, Population Health Research Institute, Hamilton, ON, Canada.
| | - Hardi Mundl
- TA Thrombosis and Vascular Medicine, Bayer AG, Wuppertal, Germany
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jaime Masjuan
- Neurology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, RICORS-ICTUS, Madrid, Spain
| | - Ivan Milanov
- Medical University, University Hospital for Neurology and Psychiatry "St Naum", Sofia, Bulgaria
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, School of Medicine, Kyorin University, Tokyo, Japan
| | - Alina Agafina
- Clinical Research Department, City Hospital #40, Saint Petersburg, Russia
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jean-Louis Mas
- Department of Neurology, GHU Paris, Hôpital Sainte-Anne, Université Paris-Cité, Inserm U1266, Paris, France
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Peter Turcani
- 1st Department of Neurology, Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Hanne Christensen
- Department of Neurology, University Hospital of Copenhagen, Bispebjerg, Denmark
| | - Jose M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Roland Veltkamp
- Neurology Department, Alfried-Krupp Hospital, Essen, Germany
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's University Hospital, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital of Basel and University of Basel, Basel, Switzerland
| | | | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium; VIB-KU Leuven Center for Brain and Disease Research, Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Adam Stepien
- Department of Neurology, Military Institute of Medicine, Warsaw, Poland
| | | | - Risto Roine
- Division of Clinical Neurosciences, University of Turku, Turku, Finland
| | - Laszlo Csiba
- DE Clinical Center (DEKK), Health Service Units, Clinics, Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Arne G Lindgren
- Department of Clinical Sciences Lund (Neurology), Lund University, Lund, Sweden; Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Bodo Kirsch
- Statistics and Data Insights, Bayer AG, Berlin, Germany
| | | | - Laura Heenan
- Department of Statistics, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
| | - Lizhen Xu
- Department of Statistics, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
| | - Robert G Hart
- Division of Neurology, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
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Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
- Jesse Dawson, Institute of Cardiovascular
and Medical Sciences, College of Medical, Veterinary and Life Sciences,
University of Glasgow, Queen Elizabeth University Hospital, Glasgow G12 9QQ, UK.
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
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Sharma M, Molina CA, Toyoda K, Bereczki D, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Diener HC, Gailani D, Kahl A, Donovan M, Perera V, Li D, Hankey GJ. Rationale and design of the AXIOMATIC-SSP phase II trial: Antithrombotic treatment with factor XIa inhibition to Optimize Management of Acute Thromboembolic events for Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2022; 31:106742. [PMID: 36037679 PMCID: PMC9619293 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106742] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Individuals with ischemic stroke or transient ischemic attack (TIA) have a high early risk of ischemic stroke despite dual antiplatelet therapy. The risk of ischemic stroke, and associated disability, represents a significant unmet clinical need. Genetic variants resulting in reduced factor XI levels are associated with reduced risk for ischemic stroke but are not associated with increased intracranial bleeding. Milvexian is an oral small-molecule inhibitor of FXIa that binds activated factor XI with high affinity and selectivity and may reduce the risk of stroke when added to antiplatelet drugs without significant bleeding. We aimed to evaluate the dose-response relationship of milvexian in participants treated with dual antiplatelets. METHODS We began a phase II, double-blinded, randomized, placebo-controlled trial at 367 sites in 2019. Participants (N = 2366) with ischemic stroke (National Institutes of Health Stroke Scale score ≤7) or high-risk TIA (ABCD2 score ≥6) were randomized to 1 of 5 doses of milvexian or placebo for 90 days. Participants also received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg for 90 days. The efficacy endpoint was the composite of ischemic stroke or incident infarct on magnetic resonance imaging. Major bleeding, defined as type 3 or 5 bleeding according to the Bleeding Academic Research Consortium, was the safety endpoint. Participant follow-up will end in 2022. CONCLUSION The AXIOMATIC-SSP trial will evaluate the dose-response of milvexian for ischemic stroke occurrence in participants with ischemic stroke or TIA.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | - Scott E Kasner
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Georgios Tsivgoulis
- National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | | | | | - Ashfaq Shuaib
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Matthias Endres
- Department Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - David Gailani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anja Kahl
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | - Danshi Li
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Graeme J Hankey
- The University of Western Australia, Perth, Australia; Perron Institute for Neurological and Translational Science, Perth, Australia
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Drug-Drug Interactions of Direct Oral Anticoagulants (DOACs): From Pharmacological to Clinical Practice. Pharmaceutics 2022; 14:pharmaceutics14061120. [PMID: 35745692 PMCID: PMC9229376 DOI: 10.3390/pharmaceutics14061120] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/24/2022] Open
Abstract
The direct oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban, and edoxaban, are becoming the most commonly prescribed drugs for preventing ischemic stroke in patients with non-valvular atrial fibrillation (NVAF) and for the treatment and prevention of venous thromboembolism (VTE). Rivaroxaban was also recently approved for the treatment of patients with a recent acute coronary syndrome (ACS). Their use demonstrated to have a favorable risk-benefit profile, with significant reductions in stroke, intracranial hemorrhage, and mortality compared to warfarin, but with increased gastrointestinal bleeding. Nevertheless, their safety profile is compromised in multimorbidity patients requiring contemporary administration of several drugs. Comorbidity and polypharmacy have a high prevalence in elderly patients, who are also more susceptible to bleeding events. The combination of multiple treatments can cause relevant drug–drug interactions (DDIs) by affecting the exposure or the pharmacological activities of DOACs. Although important differences of the pharmacokinetic (PK) properties can be observed between DOACs, all of them are substrate of P-glycoprotein (P-gp) and thus may interact with strong inducers or inhibitors of this drug transporter. On the contrary, rivaroxaban and, to a lower extent, apixaban, are also susceptible to drugs altering the cytochrome P450 isoenzyme (CYP) activities. In the present review, we summarize the potential DDI of DOACs with several classes of drugs that have been reported or have characteristics that may predict clinically significant DDIs when administered together with DOACs. Possible strategies, including dosage reduction, avoiding concomitant administration, or different time of treatment, will be also discussed to reduce the incidence of DDI with DOACs. Considering the available data from specific clinical trials or registries analysis, the use of DOACs is associated with fewer clinically relevant DDIs than warfarin, and their use represents an acceptable clinical choice. Nevertheless, DDIs can be significant in certain patient conditions so a careful evaluation should be made before prescribing a specific DOAC.
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23
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From cryptogenic to ESUS: Toward precision medicine? Rev Neurol (Paris) 2022; 178:939-952. [PMID: 35597610 DOI: 10.1016/j.neurol.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/20/2022]
Abstract
Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up. They differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. It is also different from uncommon heritable and non-heritable causes. The term embolic stroke of undetermined source (ESUS) proposed in 2014 is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. The major advantage of this definition compared to cryptogenic definition is the proposition of a specific work-up. In a general population, frequent potential sources of embolism in patients with ESUS have been suggested since a long time and include: patent foramen ovale (PFO), covert atrial fibrillation (AF), complex aortic arch atheroma, large vessel atheroma with stenosis<50%, carotid web, atrial cardiomyopathy, thrombophilia associated with cancer. It took almost 30 years to show, in patients under 60 with a cryptogenic stroke and a PFO, that PFO occlusion was superior to medical treatment alone for recurrent stroke. PFO under 60 is therefore no longer a cryptogenic cause of infarction. The concept of cryptogenic stroke and its refinement in ESUS have been fruitful for the identification of PFO associated as a cause. Covert AF can be detected by different techniques but its risk significance for recurrent stroke might be different from the simple electrocardiographic detection of AF. With the development of direct oral anticoagulants (DOAs), randomized studies in patients with ESUS, were run for stroke prevention but no difference was observed between patients treated by DOA compared to aspirin. These studies showed however the heterogeneity of ESUS patients. Further ESUS classification should be considered as a tool to identify homogeneous groups. We propose to further split the ESUS group into different subgroups: ESU-PFO>60-year-old, ESUS-ATH with stenosis<50%, ESUS-AF (covert AF & atrial cardiomyopathy), ESUS-cancer and others. Precision medicine is the ability to make targeted healthcare decisions based on the specific risks of individual patients. One preliminary stage is therefore to identify homogeneous groups suitable in the future for new therapeutic trials and, at the end, for new specific treatments.
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Mosconi MG, Paciaroni M, Ageno W. Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention? Expert Opin Investig Drugs 2022; 31:645-667. [PMID: 35486110 DOI: 10.1080/13543784.2022.2072725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. AREAS COVERED We reviewed literature from January 1st, 2000, to 15th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. EXPERT OPINION The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.
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Affiliation(s)
- Maria Giulia Mosconi
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Lattanzi S, Acampa M, Norata D, Broggi S, Caso V. A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source. Expert Opin Pharmacother 2022; 23:905-915. [PMID: 35470761 DOI: 10.1080/14656566.2022.2071125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION "Embolic stroke of undetermined source" (ESUS) is a term coined to identify non-lacunar stroke whose mechanism is likely to be embolic, and the source remains unidentified. The best antithrombotic treatment for preventing stroke recurrence in this population has not been delineated. AREAS COVERED The authors summarize and critically appraise the currently available evidence about the antithrombotic treatment for preventing stroke recurrence in patients with ESUS. Randomized trials addressing this topic were identified through MEDLINE (accessed by PubMed, as of November 2021, week 4). EXPERT OPINION Recent randomized trials have failed to demonstrate a significant benefit of direct oral anticoagulants over aspirin in reducing the recurrence of cerebral infarctions in unselected cohorts of patients with ESUS. The heterogeneity and often overlap of embolic sources may be possible explanations for the overall absence of a benefit of oral anticoagulants in ESUS as a single homogeneous entity. The results of these trials and their subgroup analyses have provided important cues to understand the pathophysiology of ESUS. They have, furthermore, increased in the interest in researchers in identifying distinct etiological phenotypes within this stroke population. There is a good rationale for ongoing and future investigations in order to tailor antithrombotic treatment according to individual features of patients with ESUS.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Davide Norata
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Grory BM, Yaghi S, Cordonnier C, Sposato LA, Romano JG, Chaturvedi S. Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies. Circ Res 2022; 130:1075-1094. [PMID: 35420910 PMCID: PMC9015232 DOI: 10.1161/circresaha.121.319947] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
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Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
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28
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Dabigatran versus aspirin for stroke prevention after cryptogenic stroke with patent foramen ovale: A prospective study. Clin Neurol Neurosurg 2022; 215:107189. [DOI: 10.1016/j.clineuro.2022.107189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/02/2022] [Accepted: 02/23/2022] [Indexed: 11/22/2022]
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Oak S, Cucchiara BL, Thau L, Nguyen TN, Sathya A, Reyes-Esteves S, Vigilante N, Kamen S, Hall J, Patel P, Garg R, Abdalkader M, Thon JM, Siegler JE. Age Alters Prevalence of Left Atrial Enlargement and Nonstenotic Carotid Plaque in Embolic Stroke of Undetermined Source. Stroke 2022; 53:2260-2267. [PMID: 35354301 DOI: 10.1161/strokeaha.121.037522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonstenotic carotid plaque and undetected atrial fibrillation are potential mechanisms of embolic stroke of undetermined source (ESUS), but it is unclear which is more likely to be the contributing stroke mechanism. We explored the relationship between left atrial enlargement (LAE) and nonstenotic carotid plaque across age ranges in an ESUS population. METHODS A retrospective multicenter cohort of consecutive patients with unilateral, anterior circulation ESUS was queried (2015 to 2021). LAE and plaque thickness were determined by transthoracic echocardiography and computed tomography angiography, respectively. Descriptive statistics were used to compare plaque features in relation to age and left atrial dimensions. RESULTS Among the 4155 patients screened, 273 (7%) met the inclusion criteria. The median age was 65 years (interquartile range [IQR] 54-74), 133 (48.7%) were female, and the median left atrial diameter was 3.5 cm (IQR 3.1-4.1). Patients with any LAE more frequently had hypertension (85.9% versus 67.2%, P<0.01), diabetes (41.0% versus 25.6%, P=0.01), dyslipidemia (56.4% versus 40.0%, P=0.01), and coronary artery disease (22.8% versus 11.3%, P=0.02). Carotid plaque thickness was greater ipsilateral versus contralateral to the stroke hemisphere in the overall cohort (median 1.9 mm [IQR 0-3] versus 1.5 mm [IQR 0-2.6], P<0.01); however, this was largely driven by the subgroup of patients without any LAE (median 1.8 mm [IQR 0-2.9] versus 1.5 mm [IQR 0-2.5], P<0.01). Compared with patients ≥70 years, younger patients had more carotid plaque ipsilateral versus contralateral (mean difference 0.42 mm±1.24 versus 0.08 mm±1.54, P=0.047) and less moderate-to-severe LAE (6.3% versus 15.3%, P=0.02). CONCLUSIONS Younger patients with ESUS had greater prevalence of ipsilateral nonstenotic plaque, while the elderly had more LAE. The differential effect of age on the probability of specific mechanisms underlying ESUS should be considered in future studies.
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Affiliation(s)
- Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Brett L Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (B.L.C., S.R.-E.)
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Anvitha Sathya
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Sahily Reyes-Esteves
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (B.L.C., S.R.-E.)
| | - Nicholas Vigilante
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Jillian Hall
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Rahul Garg
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Jesse M Thon
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
| | - James E Siegler
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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31
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Valeriani E, Potere N, Candeloro M, Spoto S, Porreca E, Rutjes AW, Di Nisio M. Extended venous thromboprophylaxis in patients hospitalized for acute ischemic stroke: A systematic review and meta-analysis. Eur J Intern Med 2022; 95:80-86. [PMID: 34649783 DOI: 10.1016/j.ejim.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Patients hospitalized for acute ischemic stroke have an increased risk of venous thromboembolism (VTE) that may persist beyond the currently recommended period of 6 to 14 days of thromboprophylaxis. This systematic review evaluated the efficacy and safety of extended venous thromboprophylaxis in patients hospitalized for acute ischemic stroke. MATERIALS AND METHODS MEDLINE, EMBASE and Clinicaltrials.gov were searched up to December 2020 for randomized controlled trials comparing extended versus standard venous thromboprophylaxis in patients hospitalized for acute ischemic stroke. The efficacy outcome was a composite of asymptomatic or symptomatic deep vein thrombosis, symptomatic pulmonary embolism, and VTE-related death. The safety outcome was major bleeding. Summary risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated using random-effects models. RESULTS Four randomized controlled trials enrolling 33718 patients were included. Of 4330 (12.8%) patients hospitalized for acute ischemic stroke, 2152 (49.7%) received extended thromboprophylaxis for four to five weeks with betrixaban (n = 405, 18.8%), enoxaparin (n = 198, 9.2%), or rivaroxaban (n = 1549, 72.0%), and 2178 (50.3%) received standard venous thromboprophylaxis with enoxaparin. VTE risk was lower in acute ischemic stroke patients receiving extended thromboprophylaxis (RR 0.67; 95% CI, 0.43 to 1.04; 13 fewer per 1000), whereas the increase in major bleeding seemed trivial when compared with standard prophylaxis (RR 1.10; 95% CI, 0.31 to 3.95; 1 more per 1000). CONCLUSION In patients hospitalized for acute ischemic stroke, the net clinical benefit may favor extended venous thromboprophylaxis for four to five weeks over standard thromboprophylaxis.
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Affiliation(s)
- Emanuele Valeriani
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico of Rome, Italy.
| | - Nicola Potere
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy; Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Silvia Spoto
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico of Rome, Italy
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Anne Ws Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti, Italy; Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Arshad F, MM S, Paplikar A, Rajendran S, Kalkonde Y, Alladi S. Vascular cognitive impairment in India: Challenges and opportunities for prevention and treatment. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2021; 3:100034. [PMID: 36324418 PMCID: PMC9616277 DOI: 10.1016/j.cccb.2021.100034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/22/2021] [Accepted: 11/23/2021] [Indexed: 06/16/2023]
Abstract
The burden of vascular contribution to cognitive impairment and dementia is substantially high in India. There are approximately 5.3 million dementia patients in India and nearly 40% are estimated to be due to vascular dementia. Several factors pose unique challenges to reducing the burden of vascular dementia and vascular cognitive impairment (VCI) in India. Wide heterogeneity in vascular risk factor profile, diversity in socioeconomic, ethnic and dietary factors, as well as regional and rural-urban differences impact uniform implementation of preventive and therapeutic strategies. There is limited evidence on the natural history of vascular disease from longitudinal cohorts in India. Additionally, the lack of advanced brain imaging and genetic information pose challenges to understanding pathophysiology and treatment response to VCI in India. Efforts are now being made to implement programmes to reduce cardiovascular risk and VCI at the population level. Cognitive and functional measures appropriate to the diverse linguistic and educational context have been developed to diagnose VCI across India. Multicentric clinical and research cohorts of stroke are also being established. Filling research gaps and developing intervention strategies for the Indian context are crucial to address the growing burden of VCI.
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Affiliation(s)
- Faheem Arshad
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Samim MM
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Avanthi Paplikar
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Srijithesh Rajendran
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | | | - Suvarna Alladi
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Kamtchum-Tatuene J, Nomani AZ, Falcione S, Munsterman D, Sykes G, Joy T, Spronk E, Vargas MI, Jickling GC. Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source. Front Neurol 2021; 12:719329. [PMID: 34630291 PMCID: PMC8492999 DOI: 10.3389/fneur.2021.719329] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023] Open
Abstract
Embolic stroke of unknown source (ESUS) represents one in five ischemic strokes. Ipsilateral non-stenotic carotid plaques are identified in 40% of all ESUS. In this narrative review, we summarize the evidence supporting the potential causal relationship between ESUS and non-stenotic carotid plaques; discuss the remaining challenges in establishing the causal link between non-stenotic plaques and ESUS and describe biomarkers of potential interest for future research. In support of the causal relationship between ESUS and non-stenotic carotid plaques, studies have shown that plaques with high-risk features are five times more prevalent in the ipsilateral vs. the contralateral carotid and there is a lower incidence of atrial fibrillation during follow-up in patients with ipsilateral non-stenotic carotid plaques. However, non-stenotic carotid plaques with or without high-risk features often coexist with other potential etiologies of stroke, notably atrial fibrillation (8.5%), intracranial atherosclerosis (8.4%), patent foramen ovale (5-9%), and atrial cardiopathy (2.4%). Such puzzling clinical associations make it challenging to confirm the causal link between non-stenotic plaques and ESUS. There are several ongoing studies exploring whether select protein and RNA biomarkers of plaque progression or vulnerability could facilitate the reclassification of some ESUS as large vessel strokes or help to optimize secondary prevention strategies.
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Affiliation(s)
- Joseph Kamtchum-Tatuene
- Faculty of Medicine and Dentistry, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Ali Z. Nomani
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Elena Spronk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Maria Isabel Vargas
- Division of Neuroradiology, Department of Radiology and Medical Imaging, Geneva University Hospital, Geneva, Switzerland
| | - Glen C. Jickling
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Barashi R, Hornik-Lurie T, Gabay H, Haskiah F, Minha S, Shuvy M, Assali A, Pereg D. Renal function and outcome of patients with non-valvular atrial fibrillation. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1180-1186. [PMID: 34458895 DOI: 10.1093/ehjacc/zuab075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/19/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022]
Abstract
AIMS Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). METHODS AND RESULTS This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325). CONCLUSIONS Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs.
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Affiliation(s)
- Rami Barashi
- Cardiology Division, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba 44281, Israel
| | | | | | - Feras Haskiah
- Cardiology Division, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba 44281, Israel
| | - Saar Minha
- Department of Cardiology, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mony Shuvy
- Cardiology Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Abid Assali
- Cardiology Division, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba 44281, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Pereg
- Cardiology Division, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba 44281, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Хрыщанович В. Dual Pathway of Inhibition and Vascular Protection in Patients with Atherosclerotic Disease. КАРДИОЛОГИЯ В БЕЛАРУСИ 2021. [DOI: 10.34883/pi.2021.13.2.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Несмотря на широкое внедрение в клиническую практику современной антитромботической стратегии (моно- или двойной антитромбоцитарной терапии), резидуальный риск неблагоприятных сердечно-сосудистых событий у пациентов с ишемической болезнью сердца (ИБС) и заболеваниями периферических артерий (ЗПА) по-прежнему остается высоким. До настоящего времени двойная антитромбоцитарная терапия является «золотым стандартом» вторичной профилактики при остром коронарном синдроме (ОКС), а монотерапия рекомендована пациентам с симптоматическим течением ЗПА, стабильной ИБС и цереброваскулярной болезнью. Вместе с тем разрыв атеросклеротической бляшки приводит не только к активации тромбоцитов, но также, вследствие экспозиции тканевого фактора, потенцирует образование тромбина. Поэтому терапевтическая стратегия, направленная на одновременное подавление генерации тромбина и активации тромбоцитов и называемая «двойной путь ингибирования», представляется более эффективной, чем известные варианты лечения, связанные с торможением только одного из двух путей. Как показали результаты исследования COMPASS, комбинация 2,5 мг ривароксабана дважды в сутки со 100 мг/сутки аспирина оказалась более эффективной по сравнению с монотерапией 100 мг/сутки аспирина в части снижения риска серьезных сердечно-сосудистых событий, незапланированных госпитализаций и летальности без увеличения количества фатальных и интракраниальных геморрагических осложнений. Преимущества режима двойного ингибирования, апробированного в исследовании COMPASS, были продемонстрированы в популяции пациентов с недавним ОКС, стабильной ИБС и ЗПА, а также после реваскуляризации нижних конечностей. На сегодняшний день ривароксабан является единственным антикоагулянтом, подтвердившим безусловные преимущества в сочетании с антитромбоцитарной терапией в указанных группах пациентов. Комбинированная терапия низкими дозами ривароксабана (2,5 мг/дважды/сутки) и аспирином (100 мг/сутки) уже включена в последние международные рекомендации как вариант вторичной профилактики у пациентов с патологией коронарных и периферических артерий.
Patients with cardiovascular (CV) disease are at high residual risk of CV events (including peripheral ischemic events), even when they receive the current antithrombotic strategies (single/dual antiplatelet therapy). Until now, dual antiplatelet therapy is the standard of care for the secondary prevention in patients with acute coronary syndrome (ACS), whereas the single antiplatelet therapy, generally with aspirin, is the standard of care for the secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. Meanwhile, atherosclerotic plaque disruption not only induces the platelet activation, but also results in thrombin generation because of tissue factor exposure. Therefore, interrupting both pathways by combining antiplatelet therapy with an anticoagulant (dual pathway inhibition [DPI]), has the potential to be more effective than inhibiting either pathway alone. The COMPASS trial showed that in comparison with aspirin 100 mg, rivaroxaban 2.5 mg twice a day plus aspirin 100 mg reduced the risk of major cardiac events, CV hospitalization, and mortality, without the increase of intracranial or fatal bleedings. The benefit of DPI using the COMPASS regimen was demonstrated in patients with the recent ACS, in chronic CAD and PAD patients, and after the lower extremity revascularization. So far, rivaroxaban is the only anticoagulant, which is effective in combination with antiplatelet therapies in the mentioned groups. The combination of low-dose rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) has been included recently into the latest international recommendations for the secondary prevention in patients with coronary or peripheral artery disease.
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Murthy SB. Troponin Elevation After Ischemic Stroke and Future Cardiovascular Risk: Is the Heart in the Right Place? J Am Heart Assoc 2021; 10:e021474. [PMID: 33982598 PMCID: PMC8200691 DOI: 10.1161/jaha.121.021474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute and Department of Neurology Weill Cornell Medicine New York NY
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Omelchenko A, Hornik-Lurie T, Gabay H, Minha S, Assali A, Pereg D. LDL Cholesterol and Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation. Am J Med 2021; 134:507-513. [PMID: 33002488 DOI: 10.1016/j.amjmed.2020.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atrial fibrillation confers higher risk of ischemic stroke, but the contribution of low-density lipoprotein cholesterol (LDL-C) levels to this risk remains unclear. We examined the association between LDL-C levels and incident stroke in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). METHODS This study was conducted using the electronic database of Clalit Health Services in Israel. Included were 21,229 patients with first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs between 2010 and 2017. Patients were categorized into 4 groups according to the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], type 2 diabetes, previous stroke or transient ischemic attack [doubled], vascular disease, age 65-74 years, and sex category) score (1-2, 3-4, 5-6, 7-9). Each group was further stratified to 4 sub-groups according to LDL-C levels (<70, 70-99, 100-130, >130 mg/dL). Ischemic stroke rates were compared among the 4 LDL-C subgroups of each CHA2DS2-VASc category. RESULTS During 56,467 person-years of follow-up, there were 2481 incidents of ischemic stroke. Higher CHA2DS2-VASc score was associated with significantly increased risk of ischemic stroke (17.5, 26.9, 46.3, 94.9 cases per 1000 person-years, for patients with CHA2DS2-VASc score of 1-2, 3-4, 5-6, and 7-9, respectively; P < .001). However, there was no association between LDL-C levels and incident ischemic stroke within each CHA2DS2-VASc score group, even following a multivariate adjustment. Subanalyses of patients with previous stroke and those treated with statins also failed to show any association between LDL-C levels and incident ischemic stroke. CONCLUSIONS Unlike the general population, LDL-C levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with DOACs. The findings support the noninclusion of dyslipidemia in ischemic stroke risk stratification of patients with atrial fibrillation.
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Affiliation(s)
| | | | | | - Saar Minha
- Department of Cardiology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Abid Assali
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - David Pereg
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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De Marchis GM. Direct Oral Anticoagulants after Ischemic Stroke: Which Patient? Which Drug? And How Early? Hamostaseologie 2021; 41:31-34. [PMID: 33588452 DOI: 10.1055/a-1329-2523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Direct oral anticoagulants (DOACs) are recommended over vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and ischemic stroke. The main advantage of DOAC over VKA is the lower rate of bleeding and mortality. This review covers challenges clinicians can encounter when treating patients with AF and ischemic stroke, including timing of DOAC start and ongoing randomized clinical trials, appropriate dosing, and available comparative evidence across DOACs. For patients without AF but with an ischemic stroke, the review outlines the role of DOACs. Finally, the risk of thrombotic events associated with specific DOAC reversal agents and DOAC pausing is reviewed.
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Affiliation(s)
- Gian Marco De Marchis
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
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Hart RG, Perera KS. Intracranial Atherosclerotic Plaque and Embolic Stroke of Undetermined Source: Another Piece of the Puzzle. J Am Coll Cardiol 2021; 77:692-694. [PMID: 33573738 DOI: 10.1016/j.jacc.2020.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University, Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Camm AJ, Atar D. Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects. Thromb Haemost 2021; 121:716-730. [PMID: 33412613 DOI: 10.1055/s-0040-1721665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,University of Oslo, Oslo, Norway
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Abstract
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeff S. Healey
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, Canada (J.S.H.)
| | - Robert G. Hart
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
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Wang QC, Wang ZY. Big Data and Atrial Fibrillation: Current Understanding and New Opportunities. J Cardiovasc Transl Res 2020; 13:944-952. [PMID: 32378163 DOI: 10.1007/s12265-020-10008-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia with diverse etiology that remarkably relates to high morbidity and mortality. With the advancements in intensive clinical and basic research, the understanding of electrophysiological and pathophysiological mechanism, as well as treatment of AF have made huge progress. However, many unresolved issues remain, including the core mechanisms and key intervention targets. Big data approach has produced new insights into the improvement of the situation. A large amount of data have been accumulated in the field of AF research, thus using the big data to achieve prevention and precise treatment of AF may be the direction of future development. In this review, we will discuss the current understanding of big data and explore the potential applications of big data in AF research, including predictive models of disease processes, disease heterogeneity, drug safety and development, precision medicine, and the potential source for big data acquisition. Grapical abstract.
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Affiliation(s)
- Qian-Chen Wang
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, China
| | - Zhen-Yu Wang
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, Hunan, China.
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Suo Y, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Yang X, Liu H, Yan H, Liu L, Zhao X, Wang Y, Li H, Wang Y. Inconsistent centralised versus non-centralised ischaemic stroke aetiology. Stroke Vasc Neurol 2020; 5:337-347. [PMID: 33154178 PMCID: PMC7804066 DOI: 10.1136/svn-2020-000576] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/03/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The Trial of Org 10 172 in Acute Stroke Treatment (TOAST) system is the most widely used aetiological categorisation system in clinical practice and research. Limited studies have validated the accuracy of routine aetiological diagnosis of patients with ischaemic stroke according to the TOAST criteria when the reported subtype is assumed to be correct. We investigated the agreement between centralised and non-centralised (site-reported, at discharge) stroke subtypes in the Third China National Stroke Registry (CNSR-III), and analysed the influence of classification consistency on evaluation during hospitalisation and for secondary prevention strategy. METHODS All patients with ischaemic stroke from the CNSR-III study with complete diffusion-weighted imaging data were included. We used multivariable Cox proportional-hazard regression models to evaluate the factors associated with consistency between centralised and non-centralised stroke subtypes. Sensitivity analyses were conducted of the subgroup of patients with complete information. RESULTS This study included 12 180 patients (mean age, 62.3 years; and women, 31.4%). Agreement between centralised and non-centralised subtype was the highest for the large-artery atherosclerosis subtype stroke (77.4% of centralised patients), followed by the small-vessel occlusion subtype (40.6% of centralised patients). Agreements for cardioembolism and stroke of other determined aetiology subtypes were 38.7% and 12.2%, respectively. Patient-level and hospital-level factors were associated with the inconsistency between centralised/non-centralised aetiological subtyping. This inconsistency was related to differences in secondary prevention strategies. Only 15.3% of the newly diagnosed patients with cardioembolism underwent centralised subtyping with indications to receive oral anticoagulants at discharge. In comparison, 51.3% of the consistent cardioembolism group and 42.0% of the centrally reassigned cardioembolism group with anticoagulation indications were prescribed oral anticoagulants. CONCLUSIONS Substantial inconsistency exists between centralised and non-centralised subtyping in China. Inaccurate aetiological subtyping could lead to inadequate secondary prevention, especially in patients with cardioembolic stroke.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huan Liu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Javalkar V, Kuybu O, Amireh A, Kelley RE. Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment. South Med J 2020; 113:585-592. [PMID: 33140113 DOI: 10.14423/smj.0000000000001173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The optimization of antithrombotic therapy for acute stroke treatment and secondary prevention is an evolving process based on an increasing array of studies that provide an evidence-based approach. Options have increased dramatically with the release of the non-vitamin K oral anticoagulants and with the results of recent randomized clinical trials designed to assess potential benefits versus risks for patients in an individualized fashion. Recent studies have provided important information to guide choice and dosing of antiplatelet agents as well as the length of treatment. Anticoagulant use is particularly pertinent for stroke prevention in patients at higher risk of atrial fibrillation and may have a place in certain other stroke mechanisms. One important focus of study is the potential benefit of combined antiplatelet and anticoagulant therapy. Options for our patients, when the initial choice of therapy does not demonstrate benefit or is not well tolerated, clearly, are valuable. For example, short-term dual antiplatelet therapy for minor stroke and transient ischemic attack is being adopted, but with the recognition that longer-term combined therapy is not worth the increased risk of bleeding. Alternative antiplatelet choices, such as cilostazol and possibly ticagrelor, may be of benefit for refractory patients and this could affect the decision-making process. This review represents an effort to incorporate the information from more recent stroke prevention and treatment studies with information gleaned from prior studies.
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Affiliation(s)
| | - Okkes Kuybu
- From the Department of Neurology, Louisiana State University Health, Shreveport
| | - Abdallah Amireh
- From the Department of Neurology, Louisiana State University Health, Shreveport
| | - Roger E Kelley
- From the Department of Neurology, Louisiana State University Health, Shreveport
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Katsanos AH, Hart RG. New Horizons in Pharmacologic Therapy for Secondary Stroke Prevention. JAMA Neurol 2020; 77:1308-1317. [DOI: 10.1001/jamaneurol.2020.2494] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Aristeidis H. Katsanos
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Robert G. Hart
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
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Abstract
Secondary cardiovascular (CV) prevention in patients with vascular disease [e.g. coronary (CAD) and peripheral (PAD) artery disease] is crucial and typically involves antiplatelet therapy with aspirin; however, managing residual ischaemic and bleeding risks in CV disease (CVD) remains a challenge. Combining the oral anticoagulant rivaroxaban (Xarelto®) with aspirin targets both the platelet and thrombotic processes of atherosclerosis, a common pathophysiological process associated with CVD. In the global COMPASS trial (n > 27,000), rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily (vs aspirin alone) significantly reduced the risk of the primary composite major adverse CV event (MACE) outcome (i.e. myocardial infarction, stroke or CV death) in adults with stable CAD and/or PAD and, in those with PAD, significantly reduced the risk of the composite major adverse limb event (MALE) outcome. Rivaroxaban + aspirin treatment was generally well tolerated; however, the risk of the composite major bleeding outcome, but not intracranial or fatal bleeding, was significantly higher with rivaroxaban + aspirin than aspirin. The increased risk for the composite major bleeding outcome did not negate the composite net clinical benefits of rivaroxaban + aspirin for secondary CV prevention, with rivaroxaban + aspirin especially beneficial in those with a greater CV risk at baseline. Ongoing clinical experience is required to fully define the role of rivaroxaban + aspirin in secondary CV prevention. In the meantime, dual therapy with rivaroxaban + aspirin is an important emerging option for secondary CV prevention of atherothrombotic events in adults with CAD or symptomatic PAD who are at high risk of ischaemic events.
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Wang F, Wang J, Cao Y, Wang L, Xu Z. Antithrombotic regimen for ischemic stroke patients with concomitant atrial fibrillation and extracranial/intracranial artery stenosis: what is the best way? Neurol Sci 2020; 41:2621-2624. [DOI: 10.1007/s10072-020-04366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/20/2020] [Indexed: 12/24/2022]
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Parascandolo E, Eisen A. Aspirin and low-dose rivaroxaban - the dual pathway concept in patients with stable atherosclerotic disease: a comprehensive review. Expert Rev Cardiovasc Ther 2020; 18:577-585. [PMID: 32755422 DOI: 10.1080/14779072.2020.1806712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cardiovascular disease is the leading cause of morbidity and mortality in adults in western nations. In the last decades, tremendous research has been conducted in the field of secondary prevention in order to reduce recurrent cardiovascular events. This review summarizes the novel dual pathway concept of aspirin and very low-dose rivaroxaban, from mechanisms to clinical practice. AREAS COVERED The COMPASS trial demonstrated that in patients with stable atherosclerotic disease, very low-dose rivaroxaban, a direct factor Xa inhibitor, when combined with aspirin, reduced the rate of recurrent ischemic events, at the cost of increased bleeding. This effect was present in patients with ischemic heart disease, as well as in patients with atherosclerosis in other beds, such as in peripheral arterial disease. Sub-studies from the COMPASS trial examined other high-risk populations who might benefit the most from this regimen. EXPERT OPINION There are currently multiple antiplatelet and anticoagulation treatment regimens for patients with stable atherosclerotic disease. The dual pathway concept is a novel approach that combines both mechanisms. Identifying patients who might benefit the most in terms of ischemic events at the least bleeding events still remains a challenge, yet prescribing this combination to high-risk patients might be the most effective.
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Affiliation(s)
- Eliot Parascandolo
- Cardiology Department, Rabin Medical Center , Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center , Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
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Weitz JI, Angiolillo DJ, Geisler T, Heitmeier S. Dual Pathway Inhibition for Vascular Protection in Patients with Atherosclerotic Disease: Rationale and Review of the Evidence. Thromb Haemost 2020; 120:1147-1158. [DOI: 10.1055/s-0040-1713376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AbstractDespite advances in secondary prevention strategies in patients with cardiovascular disease, the residual risk of recurrent atherothrombotic events remains high. Dual-antiplatelet therapy is the standard of care for secondary prevention in patients with acute coronary syndrome (ACS), whereas single antiplatelet therapy, generally with aspirin, is the standard of care for secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. However, atherosclerotic plaque disruption not only triggers platelet activation but also results in thrombin generation because of tissue factor exposure. Therefore, blocking both pathways by combining antiplatelet therapy with an anticoagulant, or dual pathway inhibition (DPI), has the potential to be more effective than inhibiting either pathway alone. The benefit of DPI has been demonstrated in the ATLAS ACS 2-TIMI 51, COMPASS, and VOYAGER PAD trials, where the combination of rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin significantly reduced the risk of atherothrombotic events compared with aspirin across a broad range of patients, including those with recent ACS, those with chronic CAD and/or PAD, and patients with PAD who have undergone peripheral revascularization. This article provides the rationale for this regimen in more detail, including why the DPI regimen with the rivaroxaban vascular dose was developed for vascular protection in a broad spectrum of patients with atherosclerotic disease.
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Affiliation(s)
- Jeffrey Ian Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
| | - Stefan Heitmeier
- Research and Development Pharmaceuticals, Bayer AG, Wuppertal, Germany
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Abstract
Stroke has traditionally been classified according to the trial of ORG 10172 in acute stroke treatment (TOAST) criteria; however, the concept of cryptogenic stroke did not meet the operational criteria necessary to define patient populations eligible for randomized studies. Therefore, the concept of embolic stroke of undetermined etiology (ESUS) was developed. An underlying hypothesis was that most strokes in patients with ESUS are caused by embolic events, hence, anticoagulation may prevent secondary events. Therefore, two large randomized trials were conducted comparing dabigatran or rivaroxaban with acetylsalicylic acid. Both studies could not show superiority of the new oral anticoagulants (NOAC) compared to aspirin; however, subgroup analyses showed that there is a patient population that may benefit from oral anticoagulation.
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Affiliation(s)
- Hans-Christoph Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät der Universität Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charite - Universitätsmedizin Berlin, Berlin, Deutschland
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