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Khalid SI, Sathianathan S, Thomson KB, McGuire LS, Soni MC, Mehta AI. 5-year stroke rates in nonvalvular atrial fibrillation after watchman compared to direct oral anticoagulants. J Cardiol 2024; 83:163-168. [PMID: 37541428 DOI: 10.1016/j.jjcc.2023.07.015] [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: 01/10/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND The WATCHMAN device (Boston Scientific; Marlborough, MA, USA) is noninferior to warfarin in preventing ischemic strokes while reducing bleeding risks associated with long term anticoagulation in nonvalvular atrial fibrillation (AFib). The device's performance compared to direct oral anticoagulants (DOAC) is less well known. OBJECTIVE To compare 5-year major bleeding and ischemic stroke rates in patients with nonvalvular AFib who received a WATCHMAN device or DOAC therapy after a major bleeding event. METHODS This retrospective, multicenter, 1:1 matched cohort study was derived from the PearlDiver Mariner database from 2010 to 2020. Patients with nonvalvular AFib on oral anticoagulation who had a major bleeding event were identified. Those who received either WATCHMAN or DOAC after resolution of the bleeding event were selected. The two groups were exactly matched 1:1 based on various comorbidities. Rates of ischemic stroke, transient ischemic attack (TIA), major bleeding, and hemorrhagic stroke were compared over 5 years. RESULTS Each cohort consisted of 2248 patients after 1:1 matching. The mean CHADS2-VASC score was 4.81 ± 1.25. At 5 years, the WATCHMAN cohort had significantly lower rates of major bleeding events [OR 0.24 (0.21, 0.27)], TIAs [OR 0.75 (0.58, 0.95)], and ischemic strokes [OR 0.72 (0.61, 0.86)]. There was no significant difference in hemorrhagic strokes [OR 1.14 (0.83, 1.58)]. CONCLUSION Even in a high-risk population, the WATCHMAN is comparable to DOAC therapy in the primary prevention of hemorrhagic strokes and may provide benefit in the rates of bleeding events, TIAs, and ischemic strokes.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Shyama Sathianathan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Kyle B Thomson
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mona C Soni
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Puy L, Parry-Jones AR, Sandset EC, Dowlatshahi D, Ziai W, Cordonnier C. Intracerebral haemorrhage. Nat Rev Dis Primers 2023; 9:14. [PMID: 36928219 DOI: 10.1038/s41572-023-00424-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/18/2023]
Abstract
Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.
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Affiliation(s)
- Laurent Puy
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France
| | - Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wendy Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlotte Cordonnier
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France.
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Veldeman M, Rossmann T, Weiss M, Conzen-Dilger C, Korja M, Hoellig A, Virta JJ, Satopää J, Luostarinen T, Clusmann H, Niemelä M, Raj R. Aneurysmal Subarachnoid Hemorrhage in Hospitalized Patients on Anticoagulants-A Two Center Matched Case-Control Study. J Clin Med 2023; 12:jcm12041476. [PMID: 36836011 PMCID: PMC9958876 DOI: 10.3390/jcm12041476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Objective-Direct oral anticoagulants (DOAC) are replacing vitamin K antagonists (VKA) for the prevention of ischemic stroke and venous thromboembolism. We set out to assess the effect of prior treatment with DOAC and VKA in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods-Consecutive SAH patients treated at two (Aachen, Germany and Helsinki, Finland) university hospitals were considered for inclusion. To assess the association between anticoagulant treatments on SAH severity measure by modified Fisher grading (mFisher) and outcome as measured by the Glasgow outcome scale (GOS, 6 months), DOAC- and VKA-treated patients were compared against age- and sex-matched SAH controls without anticoagulants. Results-During the inclusion timeframes, 964 SAH patients were treated in both centers. At the time point of aneurysm rupture, nine patients (0.93%) were on DOAC treatment, and 15 (1.6%) patients were on VKA. These were matched to 34 and 55 SAH age- and sex-matched controls, re-spectively. Overall, 55.6% of DOAC-treated patients suffered poor-grade (WFNS4-5) SAH compared to 38.2% among their respective controls (p = 0.35); 53.3% of patients on VKA suffered poor-grade SAH compared to 36.4% in their respective controls (p = 0.23). Neither treatment with DOAC (aOR 2.70, 95%CI 0.30 to 24.23; p = 0.38), nor VKA (aOR 2.78, 95%CI 0.63 to 12.23; p = 0.18) were inde-pendently associated with unfavorable outcome (GOS1-3) after 12 months. Conclusions-Iatrogenic coagulopathy caused by DOAC or VKA was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcome in hospitalized SAH patients.
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
- Correspondence: ; Tel.: +358-09-471-87409
| | - Tobias Rossmann
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, 4021 Linz, Austria
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | | | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Jyri J. Virta
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Jarno Satopää
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Teemu Luostarinen
- Anaesthesiology and Intensive Care, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
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Maduray K, Moneruzzaman M, Changwe GJ, Zhong J. Benefits and Risks Associated with Long-term Oral Anticoagulation after Successful Atrial Fibrillation Catheter Ablation: Systematic Review and Meta-analysis. Clin Appl Thromb Hemost 2022; 28:10760296221118480. [PMID: 35924410 PMCID: PMC9358599 DOI: 10.1177/10760296221118480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Oral anticoagulation (OAC) prevents thromboembolism yet greatly increases the risk of bleeding, inciting concern among clinicians. Current guidelines lack sufficient evidence supporting long-term OAC following successful atrial fibrillation catheter ablation (CA). A literature search was performed in PubMed, Google Scholar, Medline, and Scopus to seek out studies that compare continued and discontinued anticoagulation in post-ablation Atrial fibrillation (AF) patients. Funnel plots and Egger’s test examined potential bias. Via the random-effects model, summary odds ratios (OR) with 95% confidence intervals (CI) were calculated using RevMan (5.4) and STATA (17.0). Twenty studies, including 22 429 patients (13 505 off-OAC) were analyzed. Stratified CHA2DS2-VASc score ≥2 examining thromboembolic events (TE) favored OAC continuation (OR 1.86; 95% CI: 1.02-3.40; P = .04). Sensitivity analysis demonstrated this association was attenuated. The on-OAC arm had greater incidence of major bleeding (MB) (OR 0.16; 95% CI: 0.08-0.95; P < .00001), particularly intracranial hemorrhage (ICH) and gastrointestinal bleeding (GI); (OR 0.17; 95% CI: 0.08-0.36; P < .00001) and (OR 0.12; 95% CI: 0.04-0.32; P < .0001), respectively. Our findings support sustained anticoagulation in patients with a CHA2DS2-VASc score of ≥2. Due to reduced outcome robustness, physician discretion is still advised.
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Affiliation(s)
- Kellina Maduray
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, 91623Shandong University, Jinan, China
| | - Md Moneruzzaman
- Department of Physical Medicine and Rehabilitation, 572575Qilu hospital, Cheeloo college of Medicine, Shandong University, Jinan, China
| | - Geoffrey J Changwe
- Department of Cardiothoracic Surgery, 619938National Heart Hospital, Lusaka, Zambia
| | - Jingquan Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, 91623Shandong University, Jinan, China.,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Grewal K, Atzema CL, Austin PC, de Wit K, Sharma S, Mittmann N, Borgundvaag B, McLeod SL. Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study. CMAJ 2021; 193:E1561-E1567. [PMID: 35040805 PMCID: PMC8568074 DOI: 10.1503/cmaj.210811] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH. Methods: In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH. Results: We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20–1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15–1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation. Interpretation: Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.
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Affiliation(s)
- Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont.
| | - Clare L Atzema
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Peter C Austin
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Kerstin de Wit
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Sunjay Sharma
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Nicole Mittmann
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine (Grewal, Atzema), Department of Medicine, University of Toronto; ICES Central ( Grewal, Atzema, Austin); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; McMaster University (Sharma), Hamilton, Ont.; Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology, and Institute for Health Policy Management and Evaluation (Mittmann), and Department of Family and Community Medicine (Borgundvaag, McLeod), University of Toronto, Toronto, Ont
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