1
|
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.
Collapse
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
| |
Collapse
|
2
|
Kam W, Xian Y. Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants and Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase-Reply. JAMA 2022; 327:2355. [PMID: 35727281 DOI: 10.1001/jama.2022.6353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Wayneho Kam
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| |
Collapse
|
3
|
Kam W, Holmes DN, Hernandez AF, Saver JL, Fonarow GC, Smith EE, Bhatt DL, Schwamm LH, Reeves MJ, Matsouaka RA, Khan YM, Unverdorben M, Birmingham MC, Lyden PD, Asimos AW, Altschul D, Schoonover TL, Jumaa MA, Nomura JT, Suri MFK, Moore SA, Lafranchise EF, Olson D, Peterson ED, Xian Y. Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA 2022; 327:760-771. [PMID: 35143601 PMCID: PMC8832308 DOI: 10.1001/jama.2022.0948] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Current guidelines recommend against use of intravenous alteplase in patients with acute ischemic stroke who are taking non-vitamin K antagonist oral anticoagulants (NOACs). OBJECTIVE To evaluate the safety and functional outcomes of intravenous alteplase among patients who were taking NOACs prior to stroke and compare outcomes with patients who were not taking long-term anticoagulants. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 163 038 patients with acute ischemic stroke either taking NOACs or not taking anticoagulants prior to stroke and treated with intravenous alteplase within 4.5 hours of symptom onset at 1752 US hospitals participating in the Get With The Guidelines-Stroke program between April 2015 and March 2020, with complementary data from the Addressing Real-world Anticoagulant Management Issues in Stroke registry. EXPOSURES Prestroke treatment with NOACs within 7 days prior to alteplase treatment. MAIN OUTCOMES AND MEASURES The primary outcome was symptomatic intracranial hemorrhage occurring within 36 hours after intravenous alteplase administration. There were 4 secondary safety outcomes, including inpatient mortality, and 7 secondary functional outcomes assessed at hospital discharge, including the proportion of patients discharged home. RESULTS Of 163 038 patients treated with intravenous alteplase (median age, 70 [IQR, 59 to 81] years; 49.1% women), 2207 (1.4%) were taking NOACs and 160 831 (98.6%) were not taking anticoagulants prior to their stroke. Patients taking NOACs were older (median age, 75 [IQR, 64 to 82] years vs 70 [IQR, 58 to 81] years for those not taking anticoagulants), had a higher prevalence of cardiovascular comorbidities, and experienced more severe strokes (median National Institutes of Health Stroke Scale score, 10 [IQR, 5 to 17] vs 7 [IQR, 4 to 14]) (all standardized differences >10). The unadjusted rate of symptomatic intracranial hemorrhage was 3.7% (95% CI, 2.9% to 4.5%) for patients taking NOACs vs 3.2% (95% CI, 3.1% to 3.3%) for patients not taking anticoagulants. After adjusting for baseline clinical factors, the risk of symptomatic intracranial hemorrhage was not significantly different between groups (adjusted odds ratio [OR], 0.88 [95% CI, 0.70 to 1.10]; adjusted risk difference [RD], -0.51% [95% CI, -1.36% to 0.34%]). There were no significant differences in the secondary safety outcomes, including inpatient mortality (6.3% for patients taking NOACs vs 4.9% for patients not taking anticoagulants; adjusted OR, 0.84 [95% CI, 0.69 to 1.01]; adjusted RD, -1.20% [95% CI, -2.39% to -0%]). Of the secondary functional outcomes, 4 of 7 showed significant differences in favor of the NOAC group after adjustment, including the proportion of patients discharged home (45.9% vs 53.6% for patients not taking anticoagulants; adjusted OR, 1.17 [95% CI, 1.06 to 1.29]; adjusted RD, 3.84% [95% CI, 1.46% to 6.22%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke treated with intravenous alteplase, use of NOACs within the preceding 7 days, compared with no use of anticoagulants, was not associated with a significantly increased risk of intracranial hemorrhage.
Collapse
Affiliation(s)
- Wayneho Kam
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | | | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | | | - Eric E. Smith
- Department of Clinical Neurosciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Yosef M. Khan
- Health Informatics and Analytics, Center for Health Metrics and Evaluation, American Heart Association, Dallas, Texas
| | | | | | - Patrick D. Lyden
- Zilkha Neurogenetic Institute of the Keck School of Medicine, University of Southern California, Los Angeles
| | - Andrew W. Asimos
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | | | | | - Mouhammad A. Jumaa
- Department of Neurology, ProMedica Toledo Hospital, University of Toledo, Toledo, Ohio
| | - Jason T. Nomura
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | | | | | | | - DaiWai Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Eric D. Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| |
Collapse
|
4
|
Ranasinghe T, Mays T, Quedado J, Adcock A. Thrombolysis Following Heparin Reversal With Protamine Sulfate in Acute Ischemic Stroke: Case Series and Literature Review. J Stroke Cerebrovasc Dis 2019; 28:104283. [PMID: 31324409 PMCID: PMC6800047 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/23/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Administering intravenous IV tissue plasminogen activator (tPA) is the recommended standard of care in acute ischemic stroke (AIS), although it is not recommended to administer intravenous thrombolysis with tPA following heparin reversal with protamine sulfate in patients with AIS. METHODS We describe a case series of three patients and the most comprehensive literature review published to date in this specific subset of AIS patients undergoing thrombolysis following heparin reversal with protamine sulfate. The literature review was based on a scoping review methodology performed on four databases; PubMed, CINAHL, Web of Science, and Cochrane Library. All sources were searched from the inauguration of the database until February 2019. A total of six articles involving eight patients were identified. RESULTS The primary safety outcome of no symptomatic intracranial hemorrhage (sICH) was met in all eleven patients, although only seven cases had a good functional outcome at 3 months. CONCLUSIONS In appropriately selected AIS patients, coagulopathy correction appears to be safe from an sICH standpoint and may be beneficial. However, given the potential for bias with observational databases, case reports and case series, extreme caution is warranted in applying these results to routine clinical practice.
Collapse
Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, West Virginia University, Morgantown, West Virginia.
| | - Traci Mays
- Health Science Library, West Virginia University, Morgantown, West Virginia
| | - Jeff Quedado
- Department of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Amelia Adcock
- Department of Neurology, West Virginia University, Morgantown, West Virginia
| |
Collapse
|
5
|
Liu M, Zheng Y, Li G. Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:2296-2305. [PMID: 30017747 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis treatment (IVT) and endovascular therapy (EVT) have been proved as fist-line beneficial option for eligible patients who have acute ischemic stroke (AIS) with major safety concern of symptomatic intracranial hemorrhage (sICH). Unfortunately, the emergency management of patients with AIS taking vitamin K antagonists and with international normalized ratio higher than 1.7 or taking new oral anticoagulants (NOACs) represents a great challenge. We aim to comprehensively determine the safety of EVT in patients under prior-stroke anticoagulants and IVT in patients under NOAC use. METHODS Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to December 2017 were identified for analysis. Subgroup and sensitivity analyses were also conducted to evaluate the robustness of the conclusions. RESULTS Overall, 9 studies involving 3885 patients met the inclusion criteria. The rate of sICH (risk ratio [RR] = .94, 95% CI = .61-1.47, P = .799), mortality (P = .495), and recanalization (P = .655) after EVT did not differ between patients under and those who were not under anticoagulants, although patients under anticoagulants were less likely to achieve good functional outcome (P < .001) than those who were not. Moreover, prior NOAC therapy was not significantly associated with increasing sICH in patients with AIS after IVT (RR = .79, 95% CI = .41-1.53, P = .492). CONCLUSIONS Patients under anticoagulation appear to be safe after EVT with relatively lower rate of good outcome; furthermore, prior NOAC therapy was not associated with an increasing sICH rate after IVT. This offered a practical information to select appropriate therapeutic strategies for patients under anticoagulation, although the level of evidence seems to be quite shaky.
Collapse
Affiliation(s)
- Mingsu Liu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yang Zheng
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Guangqin Li
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China.
| |
Collapse
|
6
|
Yeshokumar AK, Gordon-Lipkin E, Arenivas A, Cohen J, Venkatesan A, Saylor D, Probasco JC. Neurobehavioral outcomes in autoimmune encephalitis. J Neuroimmunol 2017; 312:8-14. [DOI: 10.1016/j.jneuroim.2017.08.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/08/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
|
7
|
|
8
|
Tsivgoulis G, Safouris A. Intravenous Thrombolysis in Acute Ischemic Stroke Patients Pretreated With Non-Vitamin K Antagonist Oral Anticoagulants: An Editorial Review. Stroke 2017; 48:2031-2033. [PMID: 28536167 DOI: 10.1161/strokeaha.117.017206] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/18/2017] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Georgios Tsivgoulis
- From the Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Greece (G.T., A.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.); and Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A.S.).
| | - Apostolos Safouris
- From the Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Greece (G.T., A.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.); and Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A.S.)
| |
Collapse
|
9
|
Vaduganathan M, Bhatt DL. Gastrointestinal Bleeding With Oral Anticoagulation: Understanding the Scope of the Problem. Clin Gastroenterol Hepatol 2017; 15:691-693. [PMID: 28089849 DOI: 10.1016/j.cgh.2016.12.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 12/27/2016] [Accepted: 12/28/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Xian Y, Federspiel JJ, Hernandez AF, Laskowitz DT, Schwamm LH, Bhatt DL, Smith EE, Fonarow GC, Peterson ED. Use of Intravenous Recombinant Tissue Plasminogen Activator in Patients With Acute Ischemic Stroke Who Take Non–Vitamin K Antagonist Oral Anticoagulants Before Stroke. Circulation 2017; 135:1024-1035. [DOI: 10.1161/circulationaha.116.023940] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/17/2017] [Indexed: 01/12/2023]
Abstract
Background:
Intravenous rt-PA (recombinant tissue-type plasminogen activator) is effective in improving outcomes in ischemic stroke; however, there are few data on the use of rt-PA in patients who are receiving a non–vitamin K antagonist oral anticoagulant (NOAC).
Methods:
Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we examined the outcomes of use of thrombolytic therapy in patients with ischemic stroke who received anticoagulation with NOACs versus those on warfarin (international normalized ratio <1.7) or not on anticoagulation from 1289 registry hospitals between October 2012 and March 2015.
Results:
Of 42 887 patients with ischemic stroke treated with intravenous rt-PA within 4.5 hours, 251 were taking NOACs (dabigatran 87, rivaroxaban 129, and apixaban 35) before their stroke, 1500 were taking warfarin, and 41 136 were on neither. Patients on NOACs or warfarin were older, had more comorbid conditions, and experienced more severe strokes than did those who were not on anticoagulation (median National Institutes of Health Stroke Scale 12, 13, and 9, respectively). Unadjusted rates of symptomatic intracranial hemorrhage in the NOAC, warfarin, and none groups were 4.8%, 4.9%, and 3.9%, respectively (
P
=0.11). In comparison with those not on anticoagulation, the adjusted odds ratio for symptomatic intracranial hemorrhage for those on NOACs was 0.92 (95% confidence interval, 0.51–1.65) and for those on warfarin the adjusted odds ratio was 0.85 (95% confidence interval, 0.66–1.10). There were also no significant differences in the risk for life-threatening/serious systemic hemorrhage, any rt-PA complication, in-hospital mortality, and modified Rankin Scale at discharge across 3 groups. Similar results were also found after propensity score matching.
Conclusions:
Although experience of using rt-PA in patients with ischemic stroke on a NOAC is limited, these preliminary observations suggest that rt-PA appears to be reasonably well tolerated without prohibitive risks for adverse events among selected NOAC-treated patients. Future studies should evaluate the safety and efficacy of intravenous rt-PA in patients with ischemic stroke who are taking NOACs.
Collapse
Affiliation(s)
- Ying Xian
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Jerome J. Federspiel
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Adrian F. Hernandez
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Daniel T. Laskowitz
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Lee H. Schwamm
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Deepak L. Bhatt
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Eric E. Smith
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Gregg C. Fonarow
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| | - Eric D. Peterson
- From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute,
| |
Collapse
|