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Sawczyńska K, Włodarczyk E, Pawlicka A, Kołodziejczyk B, Wrona P, Wężyk K, Homa T, Sarba P, Wróbel D, Zdrojewska K, Sobolewska M, Rolkiewicz D, Slowik A. Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes. Stroke Res Treat 2024; 2024:2285722. [PMID: 38371464 PMCID: PMC10874293 DOI: 10.1155/2024/2285722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. Materials and Methods In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). Results In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.
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Affiliation(s)
- Katarzyna Sawczyńska
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Ewa Włodarczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Bartosz Kołodziejczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Wrona
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Kamil Wężyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Physiotherapy, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Dominik Wróbel
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Kaja Zdrojewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Maria Sobolewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Dawid Rolkiewicz
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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Chang HY, Wu HW, Hung CS, Chen YH, Huang CC, Yang LT, Hwang ST, Yu JY, Lee JK, Ho YL. Costs and Cardiovascular Benefits of a Fourth-Generation Synchronous Telehealth Program on Mortality and Cardiovascular Outcomes for Patients With Atrial Fibrillation: Retrospective Cohort Study. J Med Internet Res 2024; 26:e48748. [PMID: 38190237 PMCID: PMC10804254 DOI: 10.2196/48748] [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: 05/11/2023] [Revised: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) continues to increase in modern aging society. Patients with AF are at high risk for multiple adverse cardiovascular events, including heart failure, stroke, and mortality. Improved medical care is needed for patients with AF to enhance their quality of life and limit their medical resource utilization. With advances in the internet and technology, telehealth programs are now widely used in medical care. A fourth-generation telehealth program offers synchronous and continuous medical attention in response to physiological parameters measured at home. Although we have previously shown the benefits of this telehealth program for some patients with a high risk of cardiovascular disease, its benefits for patients with AF remains uncertain. OBJECTIVE This study aims to investigate the benefits of participating in a fourth-generation telehealth program for patients with AF in relation to cardiovascular outcomes. METHODS This was a retrospective cohort study. We retrospectively searched the medical records database of a tertiary medical center in Northern Taiwan between January 2007 and December 2017. We screened 5062 patients with cardiovascular disease and enrolled 537 patients with AF, of which 279 participated in the telehealth program and 258 did not. Bias was reduced using the inverse probability of treatment weighting adjustment based on the propensity score. Outcomes were collected and analyzed, including all-cause readmission, admission for heart failure, acute coronary syndrome, ischemic stroke, systemic embolism, bleeding events, all-cause mortality, and cardiovascular death within the follow-up period. Total medical expenses and medical costs in different departments were also compared. Subgroup analyses were conducted on ischemic stroke stratified by several subgroup variables. RESULTS The mean follow-up period was 3.0 (SD 1.7) years for the telehealth group and 3.4 (SD 1.9) years for the control group. After inverse probability of treatment weighting adjustment, the patients in the telehealth program had significantly fewer ischemic strokes (2.0 vs 4.5 events per 100 person-years; subdistribution hazard ratio [SHR] 0.45, 95% CI 0.22-0.92) and cardiovascular deaths (2.5 vs 5.9 events per 100 person-years; SHR 0.43, 95% CI 0.18-0.99) at the follow-up. The telehealth program particularly benefited patients comorbid with vascular disease (SHR 0.11, 95% CI 0.02-0.53 vs SHR 1.16, 95% CI 0.44-3.09; P=.01 for interaction). The total medical expenses during follow-up were similar in the telehealth and control groups. CONCLUSIONS This study demonstrated the benefits of participating in the fourth-generation telehealth program for patients with AF by significantly reducing their ischemic stroke risk while spending the same amount on medical expenses.
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Affiliation(s)
- Hao-Yun Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hui-Wen Wu
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ying-Hsien Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Li-Tan Yang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shin-Tsyr Hwang
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiun-Yu Yu
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Business Administration, College of Management, National Taiwan University, Taipei, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Lwun Ho
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Suomalainen OP, Martinez-Majander N, Broman J, Mannismäki L, Aro A, Curtze S, Pakarinen S, Lehto M, Putaala J. Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis. J Clin Med 2023; 13:30. [PMID: 38202037 PMCID: PMC10779359 DOI: 10.3390/jcm13010030] [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: 11/01/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.
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Affiliation(s)
- Olli Pekka Suomalainen
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Nicolas Martinez-Majander
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Jenna Broman
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Laura Mannismäki
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Aapo Aro
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Sami Curtze
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Sami Pakarinen
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Mika Lehto
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Jukka Putaala
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
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