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Rohner R, Kneihsl M, Goeldlin MB, Hakim A, Branca M, Abend S, Valenzuela Pinilla W, Fenzl S, Rezny-Kasprzak B, Strbian D, Trelle S, Paciaroni M, Thomalla G, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Bonati L, Aguiar de Sousa D, Sylaja PN, Ntaios G, Koga M, Gdovinova Z, Lemmens R, Bornstein NM, Kelly P, Katan M, Horvath T, Dawson J, Fischer U. Early Versus Late Initiation of Direct Oral Anticoagulants After Ischemic Stroke in People With Atrial Fibrillation and Hemorrhagic Transformation: Prespecified Subanalysis of the Randomized Controlled ELAN Trial. Circulation 2024; 150:19-29. [PMID: 38753452 DOI: 10.1161/circulationaha.124.069324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Whether hemorrhagic transformation (HT) modifies the treatment effect of early compared with late initiation of direct oral anticoagulation in people with ischemic stroke and atrial fibrillation is unknown. METHODS This is a post hoc analysis of the ELAN trial (Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation). The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, major extracranial bleeding, systemic embolism, or vascular death within 30 days. Secondary outcomes were the individual components, 30- and 90-day functional outcome. We estimated outcomes based on HT, subclassified as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) on prerandomization imaging (core laboratory rating) using adjusted risk differences between treatment arms. RESULTS Overall, 247 of 1970 participants (12.5%) had HT (114 HI 1, 77 HI 2, 34 PH 1, 22 PH 2). For the primary outcome, the estimated adjusted risk difference (early versus late) was -2.2% (95% CI, -7.8% to 3.5%) in people with HT (HI: -4.7% [95% CI, -10.8% to 1.4%]; PH: 6.1% [95% CI, -8.5% to 20.6%]) and -0.9% (95% CI, -2.6% to 0.8%) in people without HT. Numbers of symptomatic intracranial hemorrhage were identical in people with and without HT. With early treatment, the estimated adjusted risk difference for poor 90-day functional outcome (modified Rankin Scale score, 3-6) was 11.5% (95% CI, -0.8% to 23.8%) in participants with HT (HI: 7.4% [95% CI, -6.4% to 21.2%]; PH: 25.1% [95% CI, 0.2% to 50.0%]) and -2.6% (95% CI, -7.1% to 1.8%) in people without HT. CONCLUSIONS We found no evidence of major treatment effect heterogeneity or safety concerns with early compared with late direct oral anticoagulation initiation in people with and without HT. However, early direct oral anticoagulation initiation may worsen functional outcomes in people with PH. REGISTRATION URL: http://www.clinicaltrials.gov; Unique identifier: NCT03148457.
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Affiliation(s)
- Roman Rohner
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Markus Kneihsl
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Martina B Goeldlin
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Mattia Branca
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Stefanie Abend
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Waldo Valenzuela Pinilla
- Support Center for Advanced Neuroimaging (W.V.P.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Sabine Fenzl
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Beata Rezny-Kasprzak
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Finland (D.S.)
| | | | - Maurizio Paciaroni
- Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy (M.P.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (G.T.)
| | - Patrik Michel
- Department of Neurology, University Hospital Lausanne, University of Lausanne, Switzerland (P.M.)
| | | | - Thomas Gattringer
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
| | - Leo Bonati
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
- Research Department, Reha Rheinfelden, Switzerland (L.B.)
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital and Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S.)
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India (P.N.S.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M. Koga)
| | - Zuzana Gdovinova
- Department of Neurology, P.J. Safarik University, Faculty of Medicine and University Hospital L. Pasteur Kosice, Slovakia (Z.G.)
| | - Robin Lemmens
- KU Leuven, Department of Neurosciences, Experimental Neurology; University Hospitals Leuven, Department of Neurology, Belgium (R.L.)
| | - Natan M Bornstein
- Department of Neurology, Shaare-Zedek Medical Center, Jerusalem, Israel (N.M.B.)
| | - Peter Kelly
- Stroke Clinical Trials Network Ireland, University College Dublin/Department of Neurology, Mater University Hospital (P.K.)
| | - Mira Katan
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Thomas Horvath
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, Queen Elizabeth University Hospital, University of Glasgow, UK (J.D.)
| | - Urs Fischer
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
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Rigual R, Rodríguez-Pardo J, Lorenzo-Diéguez M, Fernández-Fernández S, Torres Iglesias G, Lastras C, Ruiz-Ares G, de Leciñana MA, de Celis E, Casado-Fernández L, Hervás C, Alonso E, Díez-Tejedor E, Fuentes B. Keeping prior anticoagulation treatment in the acute phase of ischaemic stroke: the REKOALA study. J Neurol 2024; 271:4086-4094. [PMID: 38578495 PMCID: PMC11233373 DOI: 10.1007/s00415-024-12204-8] [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: 10/15/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION A consensus on the management of anticoagulated patients in the acute phase of ischaemic stroke has not yet been established. We aimed to evaluate clinical outcomes in such patients based on the continuation or discontinuation of anticoagulation. METHODS Retrospective study of patients with acute ischaemic stroke and cardioembolic source receiving anticoagulant therapy is done. Patients were classified based on the continuation or discontinuation of anticoagulation at admission. Clinical outcomes, haemorrhagic and ischaemic events were assessed. Multivariate logistic regression analysis, propensity score matching (PSM) analysis and a sub-analysis of patients with severe ischaemic stroke at admission (NIHSS score ≥ 15) were performed. RESULTS Anticoagulation was continued in 147 (78.8%) of 186 patients. Patients continuing anticoagulant had lower NIHSS (median 5 vs 18, p < 0.001). There were no differences in haemorrhagic or ischaemic events. In the multivariate analysis, good functional outcome at discharge was higher in the continuation group, OR (CI95%) 3.77 (1.2-11.2). PSM analysis adjusted for potential confounders such as NIHSS had higher rates of good functional outcomes at discharge (80% vs 36%, p = 0.004) and at 90 days (76% vs 44%, p = 0.042) in the continuation group. Patients with severe stroke in this group had lower 90-day mortality (34.6% vs 62.5%, p = 0.045) and higher rates of good clinical outcome at discharge (33.3% vs 8.3%, p = 0.032). No differences were observed in 90-day haemorrhagic or ischaemic events. CONCLUSION Continuation of anticoagulation in patients with acute ischaemic stroke and cardioembolic source did not increase the risk of intracranial haemorrhage and may be associated with better functional outcomes.
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Affiliation(s)
- Ricardo Rigual
- Universidad Autónoma de Madrid, Madrid, Spain.
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain.
| | - Jorge Rodríguez-Pardo
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Manuel Lorenzo-Diéguez
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Susana Fernández-Fernández
- Department of Radiology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Gabriel Torres Iglesias
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Clara Lastras
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Gerardo Ruiz-Ares
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - María Alonso de Leciñana
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Elena de Celis
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Laura Casado-Fernández
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Carlos Hervás
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Elisa Alonso
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Blanca Fuentes
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
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Palaiodimou L, Stefanou MI, Katsanos AH, De Marchis GM, Aguiar De Sousa D, Dawson J, Katan M, Karapanayiotides T, Toutouzas K, Paciaroni M, Seiffge DJ, Tsivgoulis G. Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis. Eur Stroke J 2024:23969873241251931. [PMID: 38742375 DOI: 10.1177/23969873241251931] [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: 05/16/2024] Open
Abstract
INTRODUCTION There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. METHODS We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. RESULTS Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56-0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. CONCLUSIONS Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Gian Marco De Marchis
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Kantonsspital St. Gallen, Switzerland
| | - Diana Aguiar De Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mira Katan
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. Lancet Neurol 2024; 23:404-417. [PMID: 38508836 DOI: 10.1016/s1474-4422(24)00037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland.
| | - Virginia Cancelloni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lorenz Räber
- Department of Cardiology, Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Gennaro N, Ferroni E, Zorzi M, Denas G, Pengo V. ISCHEMIC STROKE AND MAJOR BLEEDING WHILE ON DIRECT ORAL ANTICOAGULANTS IN NAÏVE PATIENTS WITH ATRIAL FIBRILLATION: IMPACT OF RESUMPTION OR DISCONTINUATION OF ANTICOAGULANT TREATMENT. A population-based study. Int J Cardiol 2024; 394:131369. [PMID: 37722453 DOI: 10.1016/j.ijcard.2023.131369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
AIMS We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, in patients experiencing an anticoagulation-related event (stroke or major bleeding), occurred during anticoagulation therapy for AF. METHODS AND RESULTS We performed a retrospective population-based analysis on linked claims data of patients resident in the Veneto Region, treated with DOACs for AF and discharged (2013-2020) from the hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after a 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, ischemic stroke (IS)intracranial haemorrhage (ICH), and other major bleeding events (MB) were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Overall, 1029 patients (mean age 77 years) were included in the final cohort: 23% experienced an IS, 18% an ICH, and 59% MB. Of these, 77% resumed anticoagulation. The cumulative incidence of events was significantly lower in patients resuming therapy. In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the risk of a cumulative event (HR 0.45, 95%CI 0.35-0.57, p < 0.01). Stratifying for the index event, among patients with IS (92% resumed therapy), we observed a risk reduction of 81%; in patients with ICH (64% resumed therapy), we observed a risk reduction of 64% and for patients with MB (76% resuming therapy), we observed a risk reduction of 49%. CONCLUSIONS In patients with AF who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.
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Affiliation(s)
- N Gennaro
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - E Ferroni
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - M Zorzi
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - G Denas
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy
| | - V Pengo
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy; Arianna Foundation on Anticoagulation. Bologna, Italy.
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Jiang M, Wang C, Zhang Y. Comparison of early and delayed anticoagulation therapy after ischemic stroke in patients with atrial fibrillation: a systematic review and meta-analysis. J Thromb Thrombolysis 2023; 56:603-613. [PMID: 37505339 DOI: 10.1007/s11239-023-02872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
The optimal initiation timing of oral anticoagulants (OACs) remains controversial in patients with atrial fibrillation (AF)-related acute ischemic stroke (AIS). The aim of this study is to compare the efficacy and safety of early OACs initiation with that of the delayed initiation for AIS and AF.We searched systematically the following mainstream databases: PubMed, Embase, and Web of Science from the inception to July 2023 for studies that compared the early initiation with the delayed initiation of OACs for AF-related AIS patients. Outcome measures were the incidence of hemorrhagic events, ischemic events, and combined outcomes, as well as all-cause mortality.There were 12 eligible articles included (10 cohort studies and 2 RCT), involving 11421 patients (5690 patients in the early-initiation group and 5731 in the delayed-initiation group). Meta-analysis revealed that patients receiving OACs at the early stage of stroke had a lower incidence of ischemic events (OR: 0.68; 95% CI: 0.55,0.84; p = 0.0003) and combined outcomes (OR=0.74, 95% CI (0.57,0.95), p=0.02). No significant differences were identified in the incidence of hemorrhagic events (p = 0.26) and all-cause mortality ( p = 0.20) between the groups.Early initiation of anticoagulation therapy would be preferable in lowering the incidence of ischemic events and combined outcomes in AIS patients with AF. It is safe compared to the delayed-initiation strategy. However, the conclusion of this study needs to be further validated by more well-designed RCTs.
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Affiliation(s)
- Mengjin Jiang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China.
| | - Congyao Wang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China
| | - Yaodong Zhang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China
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8
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Lyrer F, Zietz A, Seiffge DJ, Koga M, Volbers B, Wilson D, Bonetti B, Schaedelin S, Gensicke H, Yoshimura S, Macha K, Ambler G, Thilemann S, Dittrich T, Inoue M, Miwa K, Wang R, Siedler G, Biburger L, Brown MM, Jäger RH, Muir K, Traenka C, Tanaka K, Shiozawa M, Bonati LH, Peters N, Lip GYH, Lyrer PA, Cappellari M, Toyoda K, Kallmünzer B, Schwab S, Werring DJ, Engelter ST, De Marchis GM, Polymeris AA. Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation. Ann Neurol 2023; 94:43-54. [PMID: 36975022 PMCID: PMC10953352 DOI: 10.1002/ana.26654] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. METHODS Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. RESULTS Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. CONCLUSION Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.
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Affiliation(s)
- Flurina Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital University Hospital BernUniversity of BernBernSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bastian Volbers
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
- New Zealand Brain Research InstituteChristchurchNew Zealand
| | - Bruno Bonetti
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kosmas Macha
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUK
| | - Sebastian Thilemann
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kaori Miwa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ruihao Wang
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gabriela Siedler
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Luise Biburger
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Rolf H. Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic UnitDepartment of Brain Repair and Rehabilitation, UCL Institute of NeurologyLondonUK
| | - Keith Muir
- Institute of Neuroscience & PsychologyUniversity of Glasgow and Queen Elizabeth University HospitalGlasgowUK
| | - Christopher Traenka
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Kanta Tanaka
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masayuki Shiozawa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Reha RheinfeldenRheinfeldenSwitzerland
| | - Nils Peters
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
- Stroke Center, Klinik HirslandenZurichSwitzerland
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Philippe A. Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manuel Cappellari
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bernd Kallmünzer
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Stefan T. Engelter
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
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9
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Tirumandyam G, Krishna Mohan GV, Addi Palle LR, Reyaz I, Haider S, Haseeb MD, Saleem F. Early Versus Delayed Oral Anticoagulation in Patients With Acute Ischemic Stroke Due to Atrial Fibrillation: A Meta-Analysis. Cureus 2023; 15:e40801. [PMID: 37485143 PMCID: PMC10362836 DOI: 10.7759/cureus.40801] [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: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
The aim of this study was to compare the safety and efficacy of early oral anticoagulation with delayed anticoagulant therapy in patients who have had a recent stroke and have atrial fibrillation (AF). This meta-analysis was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) statement. The literature search was independently performed by two authors. We searched PubMed and Scopus using search strings that included the following terms: "stroke," "atrial fibrillation," "oral anticoagulants," "recurrent stroke," and "intracerebral hemorrhage." Our search spanned from the inception of databases to May 25, 2023. The primary outcome assessed in this study was the composite efficacy outcome (as defined by individual studies). Recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), and death from any cause were assessed as secondary outcomes. For safety analysis, bleeding events were compared between the two study groups. We included five articles in this meta-analysis, comprising a total of 7958 patients (including 3793 in the early treatment group and 4165 in the delayed treatment group). Pooled analysis showed that the risk of composite efficacy outcome (RR: 0.69, 95% CI: 0.51-0.93, p-value: 0.01) and recurrent ischemic stroke (RR: 0.71, 95% CI: 0.53-0.94, p-value: 0.02) were lower in the early treatment group. However, no significant differences were observed between the two groups in terms of all-cause mortality, intracranial hemorrhage, or bleeding events. In light of the findings, healthcare professionals should carefully evaluate the risks and benefits of early versus delayed DOAC treatment in individual patients, considering factors such as stroke severity, bleeding risk, and patient preferences.
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Affiliation(s)
- Gayathri Tirumandyam
- Internal Medicine, Siddhartha Medical College, Dr Nandamuri Taraka Rama Rao (NTR) University of Health Sciences, Tirupathi, IND
| | | | | | - Ibrahim Reyaz
- Internal Medicine, Christian Medical College and Hospital, Ludhiana, IND
| | - Salar Haider
- Medicine, King Edwards Medical University, Islamabad, PAK
| | | | - Faraz Saleem
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Akhtar Saeed Medical and Dental College, Lahore, PAK
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10
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Fischer U, Trelle S, Branca M, Salanti G, Paciaroni M, Ferrari C, Abend S, Beyeler S, Strbian D, Thomalla G, Ntaios G, Bonati LH, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Kelly P, Lemmens R, Koga M, Sylaja PN, de Sousa DA, Bornstein NM, Gdovinova Z, Seiffge DJ, Gralla J, Horvath T, Dawson J. Early versus Late initiation of direct oral Anticoagulants in post-ischaemic stroke patients with atrial fibrillatioN (ELAN): Protocol for an international, multicentre, randomised-controlled, two-arm, open, assessor-blinded trial. Eur Stroke J 2022; 7:487-495. [PMID: 36478762 PMCID: PMC9720853 DOI: 10.1177/23969873221106043] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/19/2022] [Indexed: 07/29/2023] Open
Abstract
RATIONALE Direct oral anticoagulants (DOAC) are highly effective in preventing ischaemic strokes in people with atrial fibrillation (AF). However, it is unclear how soon they should be started after acute ischaemic stroke (AIS). Early initiation may reduce early risk of recurrence but might increase the risk of haemorrhagic complications. AIM To estimate the safety and efficacy of early initiation of DOACs compared to late guideline-based initiation in people with AIS related to AF. METHODS AND DESIGN An international, multicentre, randomised (1:1) controlled, two-arm, open, assessor-blinded trial is being conducted. Early treatment is defined as DOAC initiation within 48 h of a minor or moderate stroke, or at day 6-7 following major stroke. Late treatment is defined as DOAC initiation after day 3-4 following minor stroke, after day 6-7 following moderate stroke and after day 12-14 following major stroke. Severity of stroke is defined according to imaging assessment of infarct size. SAMPLE SIZE ELAN will randomise 2000 participants 1:1 to early versus late initiation of DOACs. This assumes a risk difference of 0.5% favouring the early arm, allowing an upper limit of the 95% confidence interval up to 1.5% based on the Miettinen & Nurminen formula. OUTCOMES The primary outcome is a composite of symptomatic intracranial haemorrhage, major extracranial bleeding, recurrent ischaemic stroke, systemic embolism or vascular death at 30 ± 3 days after randomisation. Secondary outcomes include the individual components of the primary outcome at 30 ± 3 and 90 ± 7 days and functional status at 90 ± 7 days. DISCUSSION ELAN will estimate whether there is a clinically important difference in safety and efficacy outcomes following early anticoagulation with a DOAC compared to late guideline-based treatment in neuroimaging-selected people with an AIS due to AF.
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Affiliation(s)
- Urs Fischer
- Department of Neurology, University
Hospital Basel, University of Basel, Switzerland
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Sven Trelle
- CTU Bern, University of Bern, Bern,
Switzerland
| | | | - Georgia Salanti
- Institute of Social and Preventive
Medicine, University of Bern, Bern, Switzerland
| | | | - Cecilia Ferrari
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Stefanie Abend
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Seraina Beyeler
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki
University Hospital and University of Helsinki, Helsinki, Finland
| | - Götz Thomalla
- Department of Neurology, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - George Ntaios
- Department of Internal Medicine,
Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa,
Greece
| | - Leo H Bonati
- Department of Neurology, University
Hospital Basel, University of Basel, Switzerland
- Research Department, Reha Rheinfelden,
Rheinfelden, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne
University Hospital, Lausanne, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal
Hospital Aarau, Aarau, Switzerland
| | - Thomas Gattringer
- Department of Neurology, and Division
of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology,
Medical University of Graz, Graz, Austria
| | - Else Charlotte Sandset
- Department of Neurology, Oslo
University Hospital, Oslo, Norway
- The Norwegian Air Ambulance
Foundation, Oslo, Norway
| | - Peter Kelly
- Department of Neurology, Dublin Mater
Misericordiae University Hospital, Dublin, Ireland
| | - Robin Lemmens
- Department of Neurology, University
Hospitals Leuven, KU Leuven – University of Leuven, Leuven, Belgium
- VIB Center for Brain and Disease
Research, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Padmavathy N Sylaja
- Department of Neurology, Sree Chitra
Tirunal Institute for Medical Sciences and Technology, Kerala, India
| | - Diana Aguiar de Sousa
- Stroke Center, Central Lisbon
University Hospital Center, and University of LIsbon, Lisbon, Portugal
| | - Natan M Bornstein
- Department of Neurology, Shaare-Zedek
Medical Center, Jerusalem, Israel
| | - Zuzana Gdovinova
- Department of Neurology, P.J. Safarik
University and University Hospital L. Pasteur Kosice, Slovakia
| | - David J Seiffge
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and
Interventional Neuroradiology, University Hospital Bern, and University of Bern,
Bern, Switzerland
| | - Thomas Horvath
- Department of Neurology, University
Hospital Bern, and University of Bern, Bern, Switzerland
| | - Jesse Dawson
- Institute of Cardiovascular and
Medical Sciences, College of Medical, Veterinary & Life Sciences, University of
Glasgow, UK
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11
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Oldgren J, Åsberg S, Hijazi Z, Wester P, Bertilsson M, Norrving B. Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study. Circulation 2022; 146:1056-1066. [PMID: 36065821 PMCID: PMC9648987 DOI: 10.1161/circulationaha.122.060666] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND There are no evidence-based recommendations on the optimal time point to initiate non-vitamin K antagonist oral anticoagulants (NOACs) after acute ischemic stroke in patients with atrial fibrillation. We aimed to investigate the efficacy and safety of early versus delayed initiation of NOAC in these patients. METHODS TIMING (Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation) was a registry-based, randomized, noninferiority, open-label, blinded end-point study at 34 stroke units using the Swedish Stroke Register for enrollment and follow-up. Within 72 hours from stroke onset, patients were randomized to early (≤4 days) or delayed (5-10 days) NOAC initiation, with choice of NOAC at the investigators' discretion. The primary outcome was the composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or all-cause mortality at 90 days. The prespecified noninferiority margin was 3%. Secondary outcomes included the individual components of the primary outcome. RESULTS Between April 2, 2017, and December 30, 2020, 888 patients were randomized to either early (n=450) or delayed (n=438) initiation of NOAC. No patient was lost to 90-day follow-up. Mean age was 78.3 years (SD, 9.9 years); 46.2% were women; 49.1% had previously known atrial fibrillation; and 17.5% prior stroke. The primary outcome occurred in 31 patients (6.89%) assigned to early initiation and in 38 patients (8.68%) assigned to delayed NOAC initiation (absolute risk difference, -1.79% [95% CI, -5.31% to 1.74%]; Pnoninferiority=0.004). Ischemic stroke rates were 3.11% and 4.57% (risk difference, -1.46% [95% CI, -3.98% to 1.07%]) and all-cause mortality rates were 4.67% and 5.71% (risk difference, -1.04% [95% CI, -3.96% to 1.88%]) in the early and delayed groups, respectively. No patient in either group experienced symptomatic intracerebral hemorrhage. CONCLUSIONS Early initiation was noninferior to delayed start of NOAC after acute ischemic stroke in patients with atrial fibrillation. Numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages implied that the early start of NOAC was safe and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment. REGISTRATION URL: http://www. CLINICALTRIALS gov; Unique identifier: NCT02961348.
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Affiliation(s)
- Jonas Oldgren
- Uppsala Clinical Research Center (J.O., Z.H., M.B.)
- Department of Medical Sciences, Uppsala University, Sweden (J.O., S.Å., Z.H.)
| | - Signild Åsberg
- Department of Medical Sciences, Uppsala University, Sweden (J.O., S.Å., Z.H.)
| | - Ziad Hijazi
- Uppsala Clinical Research Center (J.O., Z.H., M.B.)
- Department of Medical Sciences, Uppsala University, Sweden (J.O., S.Å., Z.H.)
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University, Sweden (P.W.)
- Department of Clinical Science, Karolinska Institutet Danderyds sjukhus, Stockholm, Sweden (P.W.)
| | | | - Bo Norrving
- Department of Clinical Sciences‚ Section of Neurology‚ Lund University‚ Skåne University Hospital, Sweden (B.N.)
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12
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Palaiodimou L, Stefanou MI, Katsanos AH, Paciaroni M, Sacco S, De Marchis GM, Shoamanesh A, Malhotra K, de Sousa DA, Lambadiari V, Kantzanou M, Vassilopoulou S, Toutouzas K, Filippou DK, Seiffge DJ, Tsivgoulis G. Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:4981. [PMID: 36078915 PMCID: PMC9457225 DOI: 10.3390/jcm11174981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: There is uncertainty regarding the optimal timing for initiation of oral anticoagulation in patients with acute ischemic stroke (AIS) due to atrial fibrillation (AF). Methods: We performed a systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) and prospective observational studies to assess the efficacy and safety of early anticoagulation in AF-related AIS (within 1 week versus 2 weeks). A second comparison was performed assessing the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin-K antagonists (VKAs) in the two early time windows. The outcomes of interest were IS recurrence, all-cause mortality, symptomatic intracerebral haemorrhage (sICH) and any ICH. Results: Eight eligible studies (6 observational, 2 RCTs) were identified, including 5616 patients with AF-related AIS who received early anticoagulation. Patients that received anticoagulants within the first week after index stroke had similar rate of recurrent IS, sICH and all-cause mortality compared to patients that received anticoagulation within two weeks (test for subgroup differences p = 0.1677; p = 0.8941; and p = 0.7786, respectively). When DOACs were compared to VKAs, there was a significant decline of IS recurrence in DOAC-treated patients compared to VKAs (RR: 0.65; 95%CI: 0.52-0.82), which was evident in both time windows of treatment initiation. DOACs were also associated with lower likelihood of sICH and all-cause mortality. Conclusions: Early initiation of anticoagulation within the first week may have a similar efficacy and safety profile compared to later anticoagulation (within two weeks), while DOACs seem more effective in terms of IS recurrence and survival compared to VKAs.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, 06129 Perugia, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA 15212, USA
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, 1649-024 Lisbon, Portugal
- Institute of Anatomy and CEEM, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal
| | - Vaia Lambadiari
- Second Department of Internal Medicine, Research Institute and Diabetes Center, “Attikon” University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sofia Vassilopoulou
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios K. Filippou
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- National Organization for Medicines (EOF), 15562 Athens, Greece
| | - David J. Seiffge
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland
- Neurology and Stroke Center, Inselspital, University Hospital Bern, 3010 Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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13
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Zhong W, Yan S, Chen Z, Luo Z, Chen Y, Zhang X, Wu C, Tang W, Zhang X, Wang Y, Gu Q, Xu D, Chen H, Lou M. Stroke outcome of early antiplatelet in post-thrombolysis haemorrhagic infarction. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-328778. [PMID: 35473712 DOI: 10.1136/jnnp-2022-328778] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Initiation of early antiplatelet (EA) therapy after acute ischaemic stroke (AIS) is essential. We aimed to investigate the safety and effectiveness of EA therapy in patients who had an AIS with haemorrhagic infarction (HI) after intravenous thrombolysis (IVT). METHODS Based on a multicentre stroke registry database, patients who had an AIS with post-thrombolysis HI at 24 hours were identified. EA users and non-EA users were defined as patients with HI who received or did not receive antiplatelet therapy between 24 and 48 hours after IVT. Primary outcome was favourable outcome defined as modified Rankin Scale scores 0-2 at 3 months. Secondary outcomes were early neurological deterioration (END) and haemorrhagic transformation expansion. RESULTS A total of 842 patients with HI were identified from 24 061 thrombolytic patients within 4.5 hours, and 341 (40.5%) received EA therapy. EA users were more likely to have a favourable outcome (55.7% vs 39.5%, OR 1.565; 95% CI 1.122 to 2.182; p=0.008) and lower rate of END (12.6% vs 21.4%, OR 0.585; 95% CI 0.391 to 0.875; p=0.009) compared with non-EA users. EA therapy was not associated with haemorrhagic transformation expansion (p=0.125). After propensity score matching, EA therapy was still independently associated with favourable outcome (54.3% vs 46.3%, OR 1.495; 95% CI 1.031 to 2.167; p=0.038) and lower risk of END (13.5% vs 21.2%, OR 0.544; 95% CI 0.350 to 0.845; p=0.007). CONCLUSIONS Antiplatelet therapy can be safely used between 24 and 48 hours when HI occurs after IVT, and such therapy is associated with reduced risk of END and improved neurological outcome in patients who had an AIS.
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Affiliation(s)
- Wansi Zhong
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhongyu Luo
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yi Chen
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xuting Zhang
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chenglong Wu
- Neurology, Shaoxing People's Hospital, Shaoxing, China
| | - Weiguo Tang
- Neurology, Zhoushan Hospital, Zhoushan, China
| | | | - Yaxian Wang
- Neurology, Huzhou Central Hospital, Huzhou, China
| | - Qun Gu
- Neurology, Huzhou First People's Hospital, Huzhou, China
| | - Dongjuan Xu
- Neurology, Dongyang People's Hospital, Jinhua, China
| | | | - Min Lou
- Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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