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Rohner R, Kneihsl M, Goeldlin MB, Hakim A, Branca M, Abend S, Valenzuela Pinilla W, Fenzl S, Rezny-Kasprzak B, Strbian D, Trelle S, Paciaroni M, Thomalla G, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Bonati L, Aguiar de Sousa D, Sylaja PN, Ntaios G, Koga M, Gdovinova Z, Lemmens R, Bornstein NM, Kelly P, Katan M, Horvath T, Dawson J, Fischer U. Early Versus Late Initiation of Direct Oral Anticoagulants After Ischemic Stroke in People With Atrial Fibrillation and Hemorrhagic Transformation: Prespecified Subanalysis of the Randomized Controlled ELAN Trial. Circulation 2024; 150:19-29. [PMID: 38753452 DOI: 10.1161/circulationaha.124.069324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Whether hemorrhagic transformation (HT) modifies the treatment effect of early compared with late initiation of direct oral anticoagulation in people with ischemic stroke and atrial fibrillation is unknown. METHODS This is a post hoc analysis of the ELAN trial (Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation). The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, major extracranial bleeding, systemic embolism, or vascular death within 30 days. Secondary outcomes were the individual components, 30- and 90-day functional outcome. We estimated outcomes based on HT, subclassified as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) on prerandomization imaging (core laboratory rating) using adjusted risk differences between treatment arms. RESULTS Overall, 247 of 1970 participants (12.5%) had HT (114 HI 1, 77 HI 2, 34 PH 1, 22 PH 2). For the primary outcome, the estimated adjusted risk difference (early versus late) was -2.2% (95% CI, -7.8% to 3.5%) in people with HT (HI: -4.7% [95% CI, -10.8% to 1.4%]; PH: 6.1% [95% CI, -8.5% to 20.6%]) and -0.9% (95% CI, -2.6% to 0.8%) in people without HT. Numbers of symptomatic intracranial hemorrhage were identical in people with and without HT. With early treatment, the estimated adjusted risk difference for poor 90-day functional outcome (modified Rankin Scale score, 3-6) was 11.5% (95% CI, -0.8% to 23.8%) in participants with HT (HI: 7.4% [95% CI, -6.4% to 21.2%]; PH: 25.1% [95% CI, 0.2% to 50.0%]) and -2.6% (95% CI, -7.1% to 1.8%) in people without HT. CONCLUSIONS We found no evidence of major treatment effect heterogeneity or safety concerns with early compared with late direct oral anticoagulation initiation in people with and without HT. However, early direct oral anticoagulation initiation may worsen functional outcomes in people with PH. REGISTRATION URL: http://www.clinicaltrials.gov; Unique identifier: NCT03148457.
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Affiliation(s)
- Roman Rohner
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Markus Kneihsl
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Martina B Goeldlin
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Mattia Branca
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Stefanie Abend
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Waldo Valenzuela Pinilla
- Support Center for Advanced Neuroimaging (W.V.P.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Sabine Fenzl
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Beata Rezny-Kasprzak
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Finland (D.S.)
| | | | - Maurizio Paciaroni
- Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy (M.P.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (G.T.)
| | - Patrik Michel
- Department of Neurology, University Hospital Lausanne, University of Lausanne, Switzerland (P.M.)
| | | | - Thomas Gattringer
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
| | - Leo Bonati
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
- Research Department, Reha Rheinfelden, Switzerland (L.B.)
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital and Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S.)
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India (P.N.S.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M. Koga)
| | - Zuzana Gdovinova
- Department of Neurology, P.J. Safarik University, Faculty of Medicine and University Hospital L. Pasteur Kosice, Slovakia (Z.G.)
| | - Robin Lemmens
- KU Leuven, Department of Neurosciences, Experimental Neurology; University Hospitals Leuven, Department of Neurology, Belgium (R.L.)
| | - Natan M Bornstein
- Department of Neurology, Shaare-Zedek Medical Center, Jerusalem, Israel (N.M.B.)
| | - Peter Kelly
- Stroke Clinical Trials Network Ireland, University College Dublin/Department of Neurology, Mater University Hospital (P.K.)
| | - Mira Katan
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Thomas Horvath
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, Queen Elizabeth University Hospital, University of Glasgow, UK (J.D.)
| | - Urs Fischer
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
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Rigual R, Rodríguez-Pardo J, Lorenzo-Diéguez M, Fernández-Fernández S, Torres Iglesias G, Lastras C, Ruiz-Ares G, de Leciñana MA, de Celis E, Casado-Fernández L, Hervás C, Alonso E, Díez-Tejedor E, Fuentes B. Keeping prior anticoagulation treatment in the acute phase of ischaemic stroke: the REKOALA study. J Neurol 2024; 271:4086-4094. [PMID: 38578495 PMCID: PMC11233373 DOI: 10.1007/s00415-024-12204-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION A consensus on the management of anticoagulated patients in the acute phase of ischaemic stroke has not yet been established. We aimed to evaluate clinical outcomes in such patients based on the continuation or discontinuation of anticoagulation. METHODS Retrospective study of patients with acute ischaemic stroke and cardioembolic source receiving anticoagulant therapy is done. Patients were classified based on the continuation or discontinuation of anticoagulation at admission. Clinical outcomes, haemorrhagic and ischaemic events were assessed. Multivariate logistic regression analysis, propensity score matching (PSM) analysis and a sub-analysis of patients with severe ischaemic stroke at admission (NIHSS score ≥ 15) were performed. RESULTS Anticoagulation was continued in 147 (78.8%) of 186 patients. Patients continuing anticoagulant had lower NIHSS (median 5 vs 18, p < 0.001). There were no differences in haemorrhagic or ischaemic events. In the multivariate analysis, good functional outcome at discharge was higher in the continuation group, OR (CI95%) 3.77 (1.2-11.2). PSM analysis adjusted for potential confounders such as NIHSS had higher rates of good functional outcomes at discharge (80% vs 36%, p = 0.004) and at 90 days (76% vs 44%, p = 0.042) in the continuation group. Patients with severe stroke in this group had lower 90-day mortality (34.6% vs 62.5%, p = 0.045) and higher rates of good clinical outcome at discharge (33.3% vs 8.3%, p = 0.032). No differences were observed in 90-day haemorrhagic or ischaemic events. CONCLUSION Continuation of anticoagulation in patients with acute ischaemic stroke and cardioembolic source did not increase the risk of intracranial haemorrhage and may be associated with better functional outcomes.
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Affiliation(s)
- Ricardo Rigual
- Universidad Autónoma de Madrid, Madrid, Spain.
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain.
| | - Jorge Rodríguez-Pardo
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Manuel Lorenzo-Diéguez
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Susana Fernández-Fernández
- Department of Radiology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Gabriel Torres Iglesias
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Clara Lastras
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Gerardo Ruiz-Ares
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - María Alonso de Leciñana
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Elena de Celis
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Laura Casado-Fernández
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Carlos Hervás
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Elisa Alonso
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
| | - Blanca Fuentes
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Madrid, Spain
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Palaiodimou L, Stefanou MI, Katsanos AH, De Marchis GM, Aguiar De Sousa D, Dawson J, Katan M, Karapanayiotides T, Toutouzas K, Paciaroni M, Seiffge DJ, Tsivgoulis G. Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis. Eur Stroke J 2024:23969873241251931. [PMID: 38742375 DOI: 10.1177/23969873241251931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. METHODS We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. RESULTS Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56-0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. CONCLUSIONS Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Gian Marco De Marchis
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Kantonsspital St. Gallen, Switzerland
| | - Diana Aguiar De Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mira Katan
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Safouris A, Psychogios K, Palaiodimou L, Orosz P, Magoufis G, Kargiotis O, Theodorou A, Karapanayiotides T, Spiliopoulos S, Nardai S, Sarraj A, Nguyen TN, Yaghi S, Walter S, Sacco S, Turc G, Tsivgoulis G. Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment. J Stroke 2024; 26:13-25. [PMID: 38326704 PMCID: PMC10850459 DOI: 10.5853/jos.2023.01578] [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: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | | | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Orosz
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - George Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thanh N. Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
- Université Paris Cité, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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