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Meshref M, Shaheen N, Diab RA, Desouki MT, Amro Y, Khairat SM, Ali M, Ahmed MG. Successful use of therapeutic anticoagulation therapy in two patients with moderate stroke from the second day of onset: A case report and literature review. Ann Med Surg (Lond) 2022; 82:104726. [PMID: 36268411 PMCID: PMC9577847 DOI: 10.1016/j.amsu.2022.104726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/11/2022] [Accepted: 09/11/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Hemorrhagic transformation of ischemic stroke is one of the most traumatic consequences of ischemic stroke. Therefore, deciding the optimal time for anticoagulant application and its effect on clinical outcome, recurrence and risk for hemorrhagic transformation are still in quarry. The European Heart Rhythm Association recommends the usage of anticoagulants after 3–4 days after a mild stroke, 6 days after moderate stroke and 12 days after a severe stroke. Case presentation In our case report, we present two patients who started full therapeutic anticoagulation of low molecular weight heparin from the first day after moderate ischemic stroke, warfarin was added later guided by INR and discharged on oral anticoagulants for associated AF. They improved clinically with improved motor function for both upper and lower limbs, sensation and gaze without any complication followed by serial CT. Clinical discussion and conclusion As a result of this case report, clinical improvement has not been associated with hemorrhagic sequelae of anticoagulant administration on the first day. At this point, we recommend conducting a trial to study the effect of early application of anticoagulants from the first day on clinical outcome, recurrence, and hemorrhagic transfusion of stroke. The hemorrhagic transformation of ischemic stroke is one of the most traumatic outcomes. Therefore, determining the optimal time to apply anticoagulants. And their impact on clinical outcome, recurrence, and hemorrhagic transformation remains challenging. According to this case report, there are no hemorrhagic sequelae associated with the first day of anticoagulant therapy. Anticoagulation recommendations should therefore be supported or rejected based on more research.
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Riesinger L, Strobl C, Leistner DM, Gori T, Akin I, Mehr M, Kellnar A, Mahabadi AA, Bogossian H, Block M, Edelmann F, Sarafoff N, Sibbing D, Ince H, Rassaf T, Mansmann U, Mehilli J, Kääb S, Hausleiter J, Massberg S, Wakili R. Apixaban versus PhenpRocoumon: Oral AntiCoagulation plus antiplatelet tHerapy in patients with Acute Coronary Syndrome and Atrial Fibrillation (APPROACH-ACS-AF): Rationale and design of the prospective randomized parallel-group, open-label, blinded-endpoint, superiority, multicenter-trial of a triple therapy versus a dual therapy in patients with Atrial Fibrillation and Acute Coronary Syndrome undergoing coronary stenting. IJC HEART & VASCULATURE 2021; 35:100810. [PMID: 34258380 PMCID: PMC8256176 DOI: 10.1016/j.ijcha.2021.100810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND A regimen of dual (DAT) vs. triple (TAT) antithrombotic therapy reduces bleeding in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, recent evidence suggests that DAT may be associated with an increased ischemic risk. This raises the question whether DAT rather than TAT should be recommended to AF patients that undergo PCI for acute coronary syndrome (ACS), carrying a particularly high risk of both bleeding and ischemic events, studied only as subgroups of previous trials. METHODS AND DESIGN The APPROACH-ACS-AF-(DZHK-7) trial is a multicenter prospective, randomized, open-label, blinded endpoint (PROBE) trial which will include patients presenting with an ACS managed by PCI and requiring oral anticoagulation (OAC) due to AF. The trial will test, whether a DAT-regimen comprising clopidogrel plus the non-Vitamin-K-antagonist oral anticoagulant (NOAC) apixaban is superior to a TAT-regimen of vitamin-K-antagonist (VKA) plus dual anti-platelet therapy (APT) with respect to bleeding. A total of 400 patients will be randomized 1:1 to a control-arm with guideline-recommended TAT with VKA plus clopidogrel and acetylsalicylic-acid and a study arm receiving DAT comprising apixaban plus clopidogrel. Patients will be followed-up for 6 months. The primary endpoint of the study is the cumulative incidence of BARC type ≥2 bleeding, secondary endpoints include a composite clinical ischemic outcome and net clinical outcome. CONCLUSIONS APPROACH-ACS-AF is the first trial dedicated to ACS patients, testing whether in terms of bleeding a DAT with NOAC is superior to a TAT regimen with VKA in high-risk ACS patients with AF.
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Affiliation(s)
- Lisa Riesinger
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Claudia Strobl
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - David M. Leistner
- Department of Cardiology, Charité University of Medicine, Berlin, Campus Benjamin Franklin, Germany and Berlin Institute of Health (BIH), 10117 Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Tommaso Gori
- Center for Cardiology, Cardiology 1, Universitätsmedizin Mainz, Mainz, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany
| | - Michael Mehr
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Antonia Kellnar
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Amir A. Mahabadi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Harilaos Bogossian
- Märkische Kliniken GmbH, Klinikum Lüdenscheid, Lüdenscheid, Germany
- Department of Cardiology, University Witten/Herdecke, Witten, Germany
| | - Michael Block
- Department of Cardiology, Augustinum Hospital, Munich, Germany
| | - Frank Edelmann
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité University Hospital (Campus Virchow Klinikum), Berlin, Germany
| | - Nikolaus Sarafoff
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
| | - Dirk Sibbing
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Hüseyin Ince
- Department of Cardiology, Rostock University Medical Center, Rostock, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ulrich Mansmann
- Department of Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
| | - Julinda Mehilli
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Medicine I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Stefan Kääb
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Reza Wakili
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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