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Sharobeam A, Lin L, Lam C, Garcia-Esperon C, Gawarikar Y, Patel R, Lee-Archer M, Wong A, Roizman M, Gilligan A, Lee A, Tan KM, Day S, Levi C, Davis SM, Parsons M, Yan B. Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study. Stroke Vasc Neurol 2024; 9:30-37. [PMID: 37247875 PMCID: PMC10956108 DOI: 10.1136/svn-2023-002357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND The optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of previous studies is the focus on clinically overt stroke, rather than radiologically obvious diffusion-weighted imaging ischaemic lesions. We aimed to quantify silent ischaemic lesions and haemorrhages on MRI at 1 month in patients commenced on early (<4 days) vs late (≥4 days) anticoagulation. We hypothesised that there would be fewer ischaemic lesions and more haemorrhages in the early anticoagulant group at 1-month MRI. METHODS A prospective multicentre, observational cohort study was performed at 11 Australian stroke centres. Clinical and MRI data were collected at baseline and follow-up, with blinded imaging assessment performed by two authors. Timing of commencement of anticoagulation was at the discretion of the treating stroke physician. RESULTS We recruited 276 patients of whom 208 met the eligibility criteria. The average age was 74.2 years (SD±10.63), and 79 (38%) patients were female. Median National Institute of Health Stroke Scale score was 5 (IQR 1-12). Median baseline ischaemic lesion volume was 5 mL (IQR 2-17). There were a greater number of new ischaemic lesions on follow-up MRI in patients commenced on anticoagulation ≥4 days after index event (17% vs 8%, p=0.04), but no difference in haemorrhage rates (22% vs 32%, p=0.10). Baseline ischaemic lesion volume of ≤5 mL was less likely to have a new haemorrhage at 1 month (p=0.02). There was no difference in haemorrhage rates in patients with an initial ischaemic lesion volume of >5 mL, regardless of anticoagulation timing. CONCLUSION Commencing anticoagulation <4 days after stroke or TIA is associated with fewer ischaemic lesions at 1 month in AF patients. There is no increased rate of haemorrhage with early anticoagulation. These results suggest that early anticoagulation after mild-to-moderate acute ischaemic stroke associated with AF might be safe, but randomised controlled studies are needed to inform clinical practice.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Longting Lin
- University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Christina Lam
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Yash Gawarikar
- Department of Neurology, Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Ronak Patel
- Department of Neurology, Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Matthew Lee-Archer
- Department of Neurology, Northern Hospital Epping, Epping, Victoria, Australia
| | - Andrew Wong
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Michael Roizman
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Amanda Gilligan
- Neurosciences Clinical Institute, Epworth Healthcare, Richmond, Virginia, Australia
- Department of Neurology, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Andrew Lee
- Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
| | - Kee Meng Tan
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Susan Day
- The University of Sydney Northern Clinical School, St Leonards, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
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Direct oral anticoagulants in the early phase of non valvular atrial fibrillation-related acute ischemic stroke: focus on real life studies. J Thromb Thrombolysis 2019; 47:292-300. [PMID: 30470967 DOI: 10.1007/s11239-018-1775-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of non valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. In the latest years a lot of real life studies on this topic have been published. The aim of our review was to focus on these. We reviewed the PubMed databases searching articles reporting on DOACs starting time within 2 weeks from AIS onset. We selected fifteen studies, eight with retrospective, six with prospective observational and one with a prospective, open-label, single arm design. Overall, 2920 patients (47.8% females) were included. In twelve studies median or mean age of patients was over 75 years. Mean or median NIHSS ad hospital admission was ≤ 12 in all studies. About one-third of patients (32.4%) received urgent reperfusion by systemic thrombolysis or mechanical thrombectomy. About one-fifth of patients (22.8%) had large infarct size. Median starting time of DOACs was reported in thirteen studies and it ranged from 2 to 8 days. About one-half of patients (45.9%) received a low dose of DOACs. In studies reporting on median or mean CHA2DS2-VASC score, it was ≥ 3 in all. In studies reporting on median or mean HAS-BLED score, it was ≥ 2 in all. Ninety-day follow-up was available for nine studies, overall including about 2200 patients. Incidence of 90-day TIA/stroke recurrence, symptomatic haemorrhagic transformation or intracranial bleeding and all cause mortality was 2.25%, 0.90% and 1.5%, respectively. The real life evidence suggests that early starting of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality.
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Paciaroni M, Agnelli G, Ageno W, Caso V. Timing of anticoagulation therapy in patients with acute ischaemic stroke and atrial fibrillation. Thromb Haemost 2017; 116:410-6. [DOI: 10.1160/th16-03-0217] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/19/2016] [Indexed: 11/05/2022]
Abstract
SummaryIn patients with acute stroke and atrial fibrillation (AF), the risk of early recurrence has been reported to range between 0.1% and 1.3% per day. Anticoagulants are the most effective therapy for the prevention of recurrent ischaemic stroke in these patients, but randomised clinical trials have failed to produce any evidence supporting the administration of heparin within 48 hours from stroke onset as it has been associated with a non-significant reduction in the recurrence of ischaemic stroke, no substantial reduction in death and disability, and an increase in intracranial bleeding. As early haemorrhagic transformation is a major concern in the acute phase of stroke patients with AF, determining the optimal time to start anticoagulant therapy is essential. This review which focuses on the epidemiology of recurrent ischaemic stroke and haemorrhagic transformation in patients with acute ischaemic stroke and AF, proposes a model for decision making on optimal timing for initiating anticoagulation, based on currently available evidence.
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Moroni F, Masotti L, Vannucchi V, Chiarelli R, Seravalle C, Pesci A, Pallini F, Puliti S, Cimolato B, Fattorini L, Scerra C, Ristori F, Imbalzano ML, Spolveri S, Landini G, Grifoni E, Paciaroni M. Confidence in the Use of Direct Oral Anticoagulants in the Acute Phase of Nonvalvular Atrial Fibrillation-Related Ischemic Stroke Over the Years: A Real-World Single-Center Study. J Stroke Cerebrovasc Dis 2017; 27:76-82. [PMID: 28918086 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/27/2017] [Accepted: 08/03/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUD AND AIM The use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) is controversial. The aims of our study were to analyze physicians' confidence in prescribing DOACs in NVAF-related AIS, the characteristics of patients receiving DOACs, and their 90-day prognosis. MATERIAL AND METHODS Clinical records of consecutive patients admitted to our wards for NVAF-related AIS over the years 2014-2016 were reviewed. RESULTS One hundred forty-seven patients, 72.7% females, mean age ± standard deviation 83.4 ± 8.8 years, were admitted to our ward for atrial fibrillation (AF)-related AIS (38 in 2014, 47 in 2015, 62 in 2016). Of these patients, 141 had NVAF-related AIS. Median length of hospital stay was 8 days (interquartile range [IQR], 6-11). In-hospital mortality was 10.8%. Ninety-eight patients (69.5%) received DOACs for secondary prevention, with increasing percentages from 2014 (62.5%) to 2016 (88%). In 88% of them, DOACs were started during hospital stay, whereas in 12% DOACs were started during ambulatory follow-up. The median time for starting DOACs was 5 days (IQR, 3-8). In patients receiving DOACs, the median National Institutes of Health Stroke Scale score was 6 (IQR, 3-12), and large ischemic lesions were present in 48%; the median modified Rankin Scale score at hospital discharge was 3 (IQR, 1-4), whereas the score at 90 days was 2 (IQR, 1-3). At the 90-day follow-up, in patients receiving DOACs, overall mortality was 3.0%, stroke recurrence was 1%, and no patients had major intracranial or extracranial bleedings. CONCLUSION Our study suggests that physicians are becoming increasingly confident in the use of DOACs in NVAF-related AIS. The use of DOACs seems effective and safe even when started in the acute phase of stroke.
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Affiliation(s)
- Federico Moroni
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Luca Masotti
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy; Internal Medicine, San Giuseppe Hospital, Empoli, Italy.
| | - Vieri Vannucchi
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Raffaella Chiarelli
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Cristiana Seravalle
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Alessandra Pesci
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Francesca Pallini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Silvia Puliti
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Barbara Cimolato
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Lamberto Fattorini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Cornelia Scerra
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Francesca Ristori
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Maria Letizia Imbalzano
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Giancarlo Landini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
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