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Sawczyńska K, Włodarczyk E, Pawlicka A, Kołodziejczyk B, Wrona P, Wężyk K, Homa T, Sarba P, Wróbel D, Zdrojewska K, Sobolewska M, Rolkiewicz D, Slowik A. Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes. Stroke Res Treat 2024; 2024:2285722. [PMID: 38371464 PMCID: PMC10874293 DOI: 10.1155/2024/2285722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. Materials and Methods In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). Results In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.
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Affiliation(s)
- Katarzyna Sawczyńska
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Ewa Włodarczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Bartosz Kołodziejczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Wrona
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Kamil Wężyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Physiotherapy, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Dominik Wróbel
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Kaja Zdrojewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Maria Sobolewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Dawid Rolkiewicz
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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Lima do Vale MR, Buckner L, Mitrofan CG, Tramontt CR, Kargbo SK, Khalid A, Ashraf S, Mouti S, Dai X, Unwin D, Bohn J, Goldberg L, Golubic R, Ray S. A synthesis of pathways linking diet, metabolic risk and cardiovascular disease: a framework to guide further research and approaches to evidence-based practice. Nutr Res Rev 2023; 36:232-258. [PMID: 34839838 DOI: 10.1017/s0954422421000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature has provided useful insights into the important role that diet plays in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g. not properly addressing confounders and mediators) and experimental research designs (e.g. not appropriate or well designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors, with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course into the spotlight.
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Affiliation(s)
| | - Luke Buckner
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | | | | | | | - Ali Khalid
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | - Sammyia Ashraf
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | - Saad Mouti
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | - Xiaowu Dai
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | | | - Jeffrey Bohn
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
- Swiss Re Institute, Zürich, Switzerland
| | - Lisa Goldberg
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | - Rajna Golubic
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
- University of Ulster, School of Biomedical Sciences, Coleraine, UK
- University of Cambridge, School of the Humanities and Social Sciences, Cambridge, UK
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3
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Liang H, Wang X, Quan X, Qin B, Zhang J, Liang S, Liang Z. Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis. J Neurol 2023; 270:4192-4200. [PMID: 37314507 DOI: 10.1007/s00415-023-11815-x] [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: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. METHODS Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. RESULTS Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. CONCLUSION The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.
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Affiliation(s)
- Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xue Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xuemei Quan
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China.
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Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [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: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
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Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Caspers M, Holle JF, Limper U, Fröhlich M, Bouillon B. Global Coagulation Testing in Acute Care Medicine: Back to Bedside? Hamostaseologie 2022; 42:400-408. [PMID: 36549292 DOI: 10.1055/a-1938-1984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Detailed and decisive information about the patients' coagulation status is important in various emergency situations. Conventional global coagulation testing strategies are often used to provide a quick overview, but several limitations particularly in the trauma setting are well described. With the introduction of direct oral anticoagulations (DOACs), a milestone for several disease entities resulting in overall improved outcomes could be reached, but at the same time providing new diagnostic challenges for the emergency situation. DESIGN As an alternative to conventional coagulation tests, there is increasing clinical and scientific interest in the use of early whole blood strategies to provide goal-directed coagulation therapies (GDCT) and hemostatic control in critically ill patients. Viscoelastic hemostatic assays (VHAs) were therefore introduced to several clinical applications and may provide as a bedside point-of-care method for faster information on the underlying hemostatic deficiency. CONCLUSION The use of VHA-based algorithms to guide hemostatic control in emergency situations now found its way to several international guidelines for patients at risk of bleeding. With this qualitative review, we would like to focus on VHA-based GDCT and review the current evidence for its use, advantages, and challenges in the two different clinical scenarios of trauma and intracerebral bleeding/stroke management.
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Affiliation(s)
- Michael Caspers
- Department of Medicine, The Institute for Research in Operative Medicine, Faculty of Health, Witten/Herdecke University, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Johannes Fabian Holle
- Department of Neurology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Ulrich Limper
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Matthias Fröhlich
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Bertil Bouillon
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
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6
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Vinding NE, Butt JH, Olesen JB, Xian Y, Kristensen SL, Rørth R, Bonde AN, Gundlund A, Yafasova A, Weeke PE, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Association Between Inappropriately Dosed Anticoagulation Therapy With Stroke Severity and Outcomes in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024402. [PMID: 35229642 PMCID: PMC9075280 DOI: 10.1161/jaha.121.024402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Oral anticoagulation (OAC) is effective for stroke prevention in patients with atrial fibrillation. However, some patients experience stroke despite OAC therapy, and knowledge about the impact of prior treatment quality is lacking. Methods and Results Patients with atrial fibrillation on OAC therapy who had a first‐time ischemic stroke were identified in the Danish Stroke Registry (2005–2018). Patients treated with vitamin K antagonist (VKA) therapy were compared according to the international normalized ratio just before stroke (international normalized ratio <2 [subtherapeutic], international normalized ratio 2–3 [therapeutic], international normalized ratio >3 [supratherapeutic]), and patients on underdosed, appropriately dosed, and overdosed direct OAC (DOAC) therapy were compared. Stroke severity was determined using the Scandinavia Stroke Scale (0–58 points), and the risk of very severe stroke (0–14 points) was analyzed by multivariable logistic regression. One‐year mortality was determined using multivariable Cox regression. A total of 2319 patients with atrial fibrillation and stroke were included; 1196 were taking a VKA (subtherapeutic [46%], therapeutic [43%], supratherapeutic [11%]), and 1123 were taking DOAC (underdosed [23%], appropriately dosed [60%], and overdosed [17%]). Subtherapeutic and supratherapeutic VKA therapy (compared with therapeutic) and underdosed DOAC therapy (compared with appropriate and underdosed DOAC) patients were older, more often women, and more comorbid. Subtherapeutic VKA therapy was associated with very severe stroke (odds ratio [OR], 2.06 [95% CI, 1.28–3.31]), whereas supratherapeutic VKA therapy was not (OR, 1.24 [95% CI, 0.60–2.57]) compared with therapeutic VKA therapy. Patients on subtherapeutic and supratherapeutic VKA therapy had a higher 1‐year mortality (hazard ratio [HR], 1.66 [95% CI, 1.29–2.13]); HR, 1.55 [95% CI, 1.08–2.22], respectively) than those on therapeutic VKA therapy. Treatment with underdosed or overdosed DOAC therapy was not associated with very severe stroke (OR, 1.27 [95% CI, 0.76–2.15]; OR, 0.73 [95% CI, 0.37–1.43], respectively) and was not associated with 1‐year mortality (HR, 1.09 [95% CI, 0.83–1.44]; HR, 0.82 [95% CI, 0.57–1.18], respectively) than appropriate DOAC. Conclusions Half of the patients with atrial fibrillation with stroke were on inappropriate OAC therapy. Subtherapeutic VKA was associated with worse stroke severity and higher mortality rate than therapeutic VKA therapy. Neither underdosed nor overdosed DOAC was associated with worse outcomes in adjusted models compared with appropriately dosed DOAC. This study supports DOAC as a first‐line therapy over VKA.
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Affiliation(s)
- Naja E Vinding
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jawad H Butt
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jonas B Olesen
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Ying Xian
- Department of Neurology University of Texas Southwestern Medical Center Dallas TX
| | - Søren Lund Kristensen
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Rasmus Rørth
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Anders Nissen Bonde
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Anna Gundlund
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark.,Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Adelina Yafasova
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Peter E Weeke
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Gunnar H Gislason
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark.,The Danish Heart Foundation Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation Nordsjællands Hospital Hillerød Denmark.,Department of Cardiology Aalborg University Hospital Aalborg Denmark.,Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Emil L Fosbøl
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
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D'Anna L, Filippidis FT, Harvey K, Korompoki E, Veltkamp R. Ischemic stroke in oral anticoagulated patients with atrial fibrillation. Acta Neurol Scand 2022; 145:288-296. [PMID: 34766621 DOI: 10.1111/ane.13552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Ischemic strokes in orally anticoagulated patients pose challenges for acute management and secondary prevention but the characteristics of these strokes are poorly understood. We examined the clinical and imaging features, the presumed underlying etiology and the subsequent antithrombotic management. METHODS We analyzed a consecutive series of patients enrolled into the EIDASAF study, a single center, observational study of ischemic stroke patients with a diagnosis atrial fibrillation (AF) prior to the index event who had been admitted to the Hyperacute Stroke Unit of Imperial College London between 2010 and 2017. We compared patients with oral anticoagulation therapy prior admission (OACprior ) with those without anticoagulation (OACnaive ). Brain imaging was analyzed centrally. RESULTS 763 patients were included in the analysis. 481 (63%) were OACnaive while 282 (37%) were OACprior . Patients with OACprior were younger, more often had a previous history of stroke or transient ischemic attack (TIA), and more often suffered from hypertension and diabetes. In OACnaive, patients, large and deep middle cerebral artery infarcts occurred more often than in OACprior patients. The groups differed significantly in the distribution of competing etiologies underlying their stroke. At discharge, OACprior more frequently were (re)-anticoagulated compared to OACnaive patients. Within the OACprior group, patients with recurrent strokes did not differ from those with a first stroke regarding clinical characteristics and pattern of cerebral infarction but they were less frequently anticoagulated. CONCLUSIONS Ischemic strokes on OAC represent a significant proportion of AF-related strokes. There is an unmet need to better understand the causes underlying these strokes and to optimize the medical management.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience Charing Cross Hospital Imperial College Healthcare NHS Trust London UK
- Department of Brain Sciences Imperial College London London UK
| | - Filippos T. Filippidis
- Department of Primary Care and Public Health School of Public Health Imperial College London London UK
| | - Kirsten Harvey
- Department of Brain Sciences Imperial College London London UK
| | - Eleni Korompoki
- Department of Brain Sciences Imperial College London London UK
| | - Roland Veltkamp
- Department of Brain Sciences Imperial College London London UK
- Department of Neurology Alfried‐Krupp Krankenhaus Essen Germany
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
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8
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Siller T, Chandratheva A, Bücke P, Werring DJ, Seiffge D. Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option? Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.
Recent Findings
Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.
Summary
IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.
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Nakajima M, Inatomi Y, Ueda A, Ito Y, Kouzaki Y, Takita T, Wada K, Yonehara T, Terasaki T, Hashimoto Y, Ando Y. Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation - K-PLUS registry. J Clin Neurosci 2021; 89:106-112. [PMID: 34119252 DOI: 10.1016/j.jocn.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/17/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs). MATERIAL AND METHODS We collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset. RESULTS A total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40-0.78) in the DOACs group, while it was 0.98 (0.77-1.24) in the warfarin group and 0.94 (0.72-1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups. CONCLUSION Preceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.
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Affiliation(s)
- Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | | | - Akihiko Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yasuyuki Ito
- Department of Neurology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | - Yanosuke Kouzaki
- Department of Neurology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Tomohiro Takita
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kuniyasu Wada
- Department of Neurology, Kumamoto City Hospital, Kumamoto, Japan.
| | | | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.
| | | | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Amyloidosis, Nagasaki International University, Sasebo, Japan.
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10
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 452] [Impact Index Per Article: 150.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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11
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Rota E, Testa L, Di Brigida G, Agosti S, Rovere ME, Risso R, Morelli N. The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian cohort and a proposed algorithm. J Thromb Thrombolysis 2020; 50:732-738. [PMID: 32303943 DOI: 10.1007/s11239-020-02108-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Approximately 1-2% of patients with non-valvular atrial fibrillation have an acute ischemic stroke (AIS) while on direct oral anticoagulant (DOAC) treatment every year. However, current evidence on stroke subtypes, pathophysiology and factors leading to the failure of DOAC preventive therapy in a "real world" setting is still scanty. This study aimed at investigating whether there is any relationship between DOAC plasma levels and the stroke occurrence, on the basis of the phenotypic classification and pathophysiology of the stroke, in a cohort of DOAC-treated patients admitted to our hospital for AIS over 1-year period. A total of 28 patients had DOAC plasma levels determined in emergency and were included in the study, nine patients receiving dabigatran, 11 rivaroxaban and 8 apixaban. The DOAC levels were low in 8/28 patients (28.6% of the sample), intermediate in 4 (14.3%) and high in 16 (57.1%). The most prevalent stroke subtype was the small vessel disease, according to the A-S-C-O phenotypic classification, in 53.6% of our sample. The most common clinical presentation was "minor stroke" in 71.4% of the cases. There was a significantly higher proportion of patients with high DOAC levels in the small vessel group, compared to the cardioembolic group without other phenotypes. The question arises as to the most suitable clinical management of AIS in these patients on DOACs. In the current absence of clear evidence, taking into account the DOAC levels (low/intermediate/high) and the underlying stroke pathophysiology, we present a flowchart of our proposed clinical management of ischemic stroke in patients while on DOAC.
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Affiliation(s)
- E Rota
- Neurology Department, ASL Alessandria (AL), Via E. Raggio 12, 15067, Novi Ligure, AL, Italy.
| | - L Testa
- Neurology Department, ASL Alessandria (AL), Via E. Raggio 12, 15067, Novi Ligure, AL, Italy
| | - G Di Brigida
- Neurology Department, ASL Alessandria (AL), Via E. Raggio 12, 15067, Novi Ligure, AL, Italy
| | - S Agosti
- Cardiology Unit, San Giacomo Hospital, Novi Ligure, AL, Italy
| | - M E Rovere
- Cardiology Unit, San Giacomo Hospital, Novi Ligure, AL, Italy
| | - R Risso
- Internal Medicine Unit, Santo Spirito Hospital, ASL CN2, Bra, CN, Italy
| | - N Morelli
- Neurology and Radiology Unit, Guglielmo da Saliceto Hospital, AUSLPC, Piacenza, PC, Italy
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12
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Tavares SF, Ferreira I, Chaves V, Flores L, Correia C, Almeida J, Fonseca L, Castro Chaves P. Acute Ischemic Stroke Outcome and Preceding Anticoagulation: Direct Oral Anticoagulants Versus Vitamin K Antagonists. J Stroke Cerebrovasc Dis 2020; 29:104691. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022] Open
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13
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Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, Frey S, Goeldlin M, Mordasini P, Mosimann PJ, Nogueira RG, Haussen DC, Rodrigues GM, Uphaus T, L'Allinec V, Krajíčková D, Alonso A, Costalat V, Hajdu SD, Olivé-Gadea M, Maegerlein C, Pierot L, Schaafsma J, Suzuki K, Arnold M, Heldner MR, Fischer U, Kaesmacher J. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke 2020; 51:892-898. [PMID: 31992179 DOI: 10.1161/strokeaha.119.026606] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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Affiliation(s)
- Thomas R Meinel
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Joachim U Kniepert
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - David J Seiffge
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Simon Jung
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Elias Auer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Sebastién Frey
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Martina Goeldlin
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.).,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Raul G Nogueira
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Diogo C Haussen
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Gabriel M Rodrigues
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany, on behalf of the ENDOSTROKE Study Group (T.U.)
| | - Vincent L'Allinec
- Neuroradiology Department, Nantes University Hospital, France (V.L.)
| | - Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine in Hradec Králové, Charles University and University Hospital Hradec Králové, Czech Republic (D.K.)
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (A.A.)
| | | | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Switzerland (S.D.H.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | | | - Joanna Schaafsma
- Division of Neurology, University Health Network, University of Toronto, Canada (J.S.)
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan (K.S.)
| | - Marcel Arnold
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Mirjam R Heldner
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Urs Fischer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.)
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14
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Katsanos AH. Is decreased stroke severity in patients with atrial fibrillation receiving non-vitamin K oral anticoagulant treatment the coup de grâce for warfarin? Eur J Neurol 2019; 27:411-412. [PMID: 31876019 DOI: 10.1111/ene.14145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
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15
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Stroke severity in patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists. J Neurol 2019; 266:2263-2272. [DOI: 10.1007/s00415-019-09412-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
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