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Vasquez MA, Lambrakos LK, Velasquez A, Goldberger JJ, Mitrani RD. Contemporary outcomes of acute ischemic stroke in atrial fibrillation patients on anticoagulation. J Stroke Cerebrovasc Dis 2024; 33:107790. [PMID: 38788986 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107790] [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: 02/13/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Long-term anticoagulation (AC) therapy reduces the risk of stroke in patients with Atrial Fibrillation (AF). However, data on the impact of AC on in-hospital stroke outcomes is lacking. METHODS The National Inpatient Sample was used to identify adult inpatients with AF and a primary diagnosis of ischemic stroke between 2016 and 2020. Data was stratified between AC users and nonusers. A multivariate regression model was used to describe the in-hospital outcomes, adjusting for significant comorbidities. RESULTS A total of 655,540 hospitalizations with AF and a primary hospitalization diagnosis of ischemic stroke were included, of which 194,560 (29.7 %) were on long-term AC. Patients on AC tended to be younger (mean age, 77 vs. 78), had a higher average CHA2DS2VASc score (4.48 vs. 4.20), higher rates of hypertension (91 % vs. 88 %), hyperlipidemia (64 % vs. 59 %), and heart failure (34 % vs. 30 %) compared to patients not on long-term AC. Use of AC was associated with decreased in-hospital mortality (aOR [95 % CI]: 0.62 [0.60-0.63]), decreased stroke severity (mean NIHSS, 8 vs. 10), decreased use of tPA (aOR 0.42 [0.41-0.43]), mechanical thrombectomy (aOR 0.85 [0.83-0.87]), intracranial hemorrhage (aOR 0.69 [0.67-0.70]), gastrointestinal bleeding (aOR 0.74 [0.70-0.77]), and discharge to skilled nursing facilities (aOR 0.90 [0.89-0.91]), compared to patients not on AC (P<0.001 for all comparisons). CONCLUSION Among patients with AF admitted for acute ischemic stroke, AC use prior to stroke was associated with decreased in-hospital mortality, decreased stroke severity, decreased discharge to SNF, and fewer stroke-related and bleeding complications.
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Affiliation(s)
- Moises A Vasquez
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, C-600D, Miami, FL 33136, USA.
| | - Litsa K Lambrakos
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alex Velasquez
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jeffrey J Goldberger
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Raul D Mitrani
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
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Dubé MC, Ducroux C, Daneault N, Deschaintre Y, Jacquin G, Odier C, Stapf C, Poppe AY, Romanelli G, Gioia LC. Characteristics of Ischemic Stroke Despite Oral Anticoagulant Use For Atrial Fibrillation. Can J Neurol Sci 2024:1-4. [PMID: 38232961 DOI: 10.1017/cjn.2024.3] [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: 01/19/2024]
Abstract
Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.
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Affiliation(s)
- Marie-Christine Dubé
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Célina Ducroux
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Nicole Daneault
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Grégory Jacquin
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Céline Odier
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Christian Stapf
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Giovanni Romanelli
- Department of Medicine (Cardiology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Laura C Gioia
- Department of Neurosciences, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Neurovascular Group, Neurosciences Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
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Crispino P. Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both? Neurol Int 2023; 15:1443-1458. [PMID: 38132972 PMCID: PMC10745771 DOI: 10.3390/neurolint15040093] [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: 10/15/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.
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Affiliation(s)
- Pietro Crispino
- Medicine Unit, Santa Maria Goretti Hospital, Via Scaravelli Snc, 04100 Latina, Italy
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Xue S, Na R, Dong J, Wei M, Kong Q, Wang Q, Qiu X, Li F, Song H. Characteristics and Mechanism of Acute Ischemic Stroke in NAVF Patients With Prior Oral Anticoagulant Therapy. Neurologist 2023; 28:379-385. [PMID: 37582631 PMCID: PMC10627545 DOI: 10.1097/nrl.0000000000000504] [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: 08/17/2023]
Abstract
OBJECTIVES We aimed to analyze the characteristics and mechanisms of acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) who received prior anticoagulant therapy. METHODS We retrospectively analyzed the data of patients with NVAF and AIS between January 2016 and December 2021. Patients were divided into non-anticoagulant, adequate anticoagulant, and insufficient anticoagulant groups according to their prior anticoagulant status. Patients with prior anticoagulant therapy were further divided into warfarin and direct oral anticoagulant groups. RESULTS A total of 749 patients (661 without anticoagulants, 33 with adequate anticoagulants, and 55 with insufficient anticoagulants) were included. Patients with adequate anticoagulant had a milder National Institute of Health Stroke Scale at presentation ( P =0.001) and discharge ( P =0.003), a higher proportion of Modified Rankin Scale (mRS) ≤2 at discharge ( P =0.011), and lower rates of massive infarction ( P =0.008) than patients without anticoagulant. Compared with the non-anticoagulant group, the proportion of intravenous thrombolysis was significantly lower in the adequate anticoagulant ( P <0.001) and insufficient anticoagulant ( P =0.009) groups. Patients in the adequate anticoagulant group had higher rates of responsible cerebral atherosclerotic stenosis ( P =0.001 and 0.006, respectively) and competing large artery atherosclerotic mechanisms ( P =0.006 and 0.009, respectively) than those in the other 2 groups. Compared with warfarin, direct oral anticoagulant was associated with higher rates of Modified Rankin Scale ≤2 at discharge ( P =0.003). CONCLUSIONS Adequate anticoagulant therapy may be associated with milder stroke severity and better outcomes at discharge in patients with NVAF. Competing large artery atherosclerotic mechanisms may be associated with anticoagulant failure in patients with NAVF with prior adequate anticoagulant therapy.
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Affiliation(s)
- Sufang Xue
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Risu Na
- Department of Neurology, Tongliao City Hospital, Tongliao, China
| | - Jing Dong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qi Kong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qiujia Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xue Qiu
- Department of Neurology, Shuangqiao Hospital, Beijing, China
| | - Fangyu Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
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Caliandro P, Cancelloni V, Marco M, Reale G, Zauli A, Agnelli G, Caso V, Becattini C, Calabresi P, Giulia Mosconi M, Giustozzi M, Tsivgoulis G, Julian Seiffge D, Engelter ST, Lyrer P, Polymeris AA, Dittrich T, Zietz A, Marco De Marchis G, Putaala J, Strbian D, Tomppo L, Michel P, Strambo D, Salerno A, Remillard S, Buehrer M, Bavaud O, Vanacker P, Zuurbier S, Yperzeele L, Loos CM, Cappellari M, Emiliani A, Zedde M, Abdul-Rahim A, Dawson J, Cronshaw R, Schirinzi E, Del Sette M, Stretz C, Kala N, Reznik M, Schomer A, Mac Grory B, Jayaraman M, McTaggart R, Yaghi S, Furie KL, Masotti L, Grifoni E, Toni D, Risitano A, Falcou A, Petraglia L, Maria Lotti E, Padroni M, Pavolucci L, Lochner P, Silvestrelli G, Ciccone A, Alberti A, Venti M, Leone De Magistris I, Kargiotis O, Rocco A, Diomedi M, Marcheselli S, Antonenko K, Rota E, Tassinari T, Saia V, Palmerini F, Aridon P, Arnao V, Monaco S, Cottone S, Baldi A, D’Amore C, Ageno W, Pegoraro S, Ntaios G, Sagris D, Giannopoulos S, Kosmidou M, Ntais E, Romoli M, Pantoni L, Rosa S, Bertora P, Chiti A, Canavero I, Emanuele Saggese C, Plocco M, Giorli E, Palaiodimou L, Bakola E, Bandini F, Gasparro A, Terruso V, Mannino M, Pezzini A, Ornello R, Sacco S, Popovic N, Scoditti U, Genovese A, Denti L, Flomin Y, Mancuso M, Ferrari E, Chiara Caselli M, Ulivi L, Giannini N, Vadikolias K, Liantinioti C, Chondrogianni M, Halvatsiotis P, Carletti M, Karagkiozi E, Athanasakis G, Makaritsis K, Lanari A, Tatlisumak T, Acciarresi M, Vannucchi V, Lorenzini G, Tassi R, Guideri F, Acampa M, Martini G, Sohn SI, Mumoli N, Tadi P, Letteri F, Maccarrone M, Poli L, Magoni M, Galati F, Tiseo C, Gourbali V, Orlandi G, Giuntini M, Corea F, Bellesini M, Girardi L, Maimone Baronello M, Karapanayiotides T, Rueckert C, Csiba L, Szabó L, Rigatelli A, Imberti D, Zabzuni D, Pieroni A, Barlinn K, Pallesen LP, Barlinn J, Doronin B, Volodina V, Deleu D, Bonetti B, Porta C, Gentile L, Eskandari A, Paciaroni M. Risk of recurrent stroke in patients with atrial fibrillation treated with oral anticoagulants alone or in combination with anti-platelet therapy. Eur Stroke J 2023; 8:722-730. [PMID: 37458099 PMCID: PMC10472945 DOI: 10.1177/23969873231183211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. PATIENTS AND METHODS We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). RESULTS During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01-1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48-3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02-2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19-3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01-1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06-4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23-4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35-2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45-2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06-3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05-2.74]). DISCUSSION Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. CONCLUSION Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.
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Herlekar R, Sur Roy A, Hajiev S, Induruwa I, Agarwal S, Evans NR, Khadjooi K, Markus H, O’Brien E, Warburton E, Zachariah G, McCabe JJ. The contribution of competing mechanisms in stroke despite anticoagulation in patients with atrial fibrillation. Eur Stroke J 2023; 8:541-548. [PMID: 37231697 PMCID: PMC10334183 DOI: 10.1177/23969873231168367] [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: 12/05/2022] [Accepted: 03/20/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND For reasons poorly understood, strokes frequently occur in patients with atrial fibrillation (AF) despite oral anticoagulation. Better data are needed to inform randomised trials (RCTs) of new strategies to prevent recurrence in these patients. We investigate the relative contribution of competing stroke mechanisms in patients with AF who have stroke despite anticoagulation (OAC+) compared with those who are anticoagulant naïve (OAC-) at the time of their event. PATIENTS AND METHODS We performed a cross-sectional study leveraging data from a prospective stroke registry (2015-2022). Eligible patients had ischemic stroke and AF. Stroke classification was performed by a single stroke-specialist blinded to OAC status using TOAST criteria. The presence of atherosclerotic plaque was determined using duplex ultrasonography, computerised tomography (CT) or magnetic resonance (MR) angiography. Imaging was reviewed by a single reader. Logistic regression was used to identify independent predictors of stroke despite anticoagulation. RESULTS Of 596 patients included, 198 (33.2%) were in the OAC+ group. A competing cause for stroke was more frequent in patients with OAC+ versus OAC- (69/198 (34.8%)) versus 77/398 (19.3%), p < 0.001). After adjustment, both small vessel occlusion (odds ratio (OR): 2.46, 95% CI: 1.20-5.06) and arterial atheroma (⩾50% stenosis) (OR: 1.78, 95% CI: 1.07-2.94) were independently associated with stroke despite anticoagulation. DISCUSSION AND CONCLUSION Patients with AF-associated stroke despite OAC are much more likely than patients who are OAC-naïve to have competing stroke mechanisms. Rigorous investigation for alternative stroke causes in stroke despite OAC has a high diagnostic yield. These data should be used to guide patient selection for future RCTs in this population.
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Affiliation(s)
- Rahul Herlekar
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Akangsha Sur Roy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Saur Hajiev
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Isuru Induruwa
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Smriti Agarwal
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Kayvan Khadjooi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Hugh Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Eoin O’Brien
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - George Zachariah
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John J McCabe
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Dublin, Ireland
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Dublin, Ireland
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Bhatia K, Ladd LM, Carr KH, Di Napoli M, Saver JL, McCullough LD, Hosseini Farahabadi M, Alsbrook DL, Hinduja A, Ortiz Garcia JG, Sabbagh SY, Jafarli A, Divani AA. Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines. Curr Neurol Neurosci Rep 2023; 23:235-262. [PMID: 37037980 DOI: 10.1007/s11910-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.
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Affiliation(s)
- Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lindsey M Ladd
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kelsey H Carr
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, the University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Alibay Jafarli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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8
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Wang X, Fa J, Zhang Y, Huang S, Liu J, Gao J, Xing L, Liu Z, Wang X. Evaluation of Herb–Drug Interaction Between Danshen and Rivaroxaban in Rat and Human Liver Microsomes. Front Pharmacol 2022; 13:950525. [PMID: 35928264 PMCID: PMC9343791 DOI: 10.3389/fphar.2022.950525] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
The combination of Salvia miltiorrhiza (Danshen) and rivaroxaban is a promising treatment option in clinical practice in China, but the herb–drug interaction between Danshen and rivaroxaban remains unclear. Therefore, this study aims to reveal the interaction between Danshen and rivaroxaban. We not only investigated the inhibitory properties of Danshen tablet on rivaroxaban metabolism in rat and human liver microsomes but also evaluated the inhibitory effects of Danshen tablet and its eight active components (dihydrotanshinone I, tanshinone I, tanshinone IIA, cryptotanshinone, danshensu, salvianolic acid A, salvianolic acid B, and salvianolic acid C) on cytochrome P450 (CYP) enzymes. The results showed that Danshen tablet potently inhibited the metabolism of rivaroxaban in rat and human liver microsomes. In the CYP inhibition study, we found that dihydrotanshinone I, the active component of Danshen tablet, potently inhibited the activities of rat CYP3A and CYP2J, with IC50 values at 13.85 and 6.39 μM, respectively. In further inhibition kinetic study, we found that Danshen tablet is a mixed inhibitor in rivaroxaban metabolism in rat and human liver microsomes, with the Ki value at 0.72 and 0.25 mg/ml, respectively. In conclusion, there is a potential interaction between Danshen tablet and rivaroxaban. Danshen tablet inhibits the metabolism of rivaroxaban, which may be because its lipid-soluble components such as dihydrotanshinone I strongly inhibit the activities of CYP enzymes, especially CYP3A and CYP2J. Therefore, when Danshen tablet and rivaroxaban are used simultaneously in the clinic, it is necessary to strengthen the drug monitoring of rivaroxaban and adjust the dosage.
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Affiliation(s)
- Xu Wang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jingjing Fa
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuanjin Zhang
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences, School of Life Sciences, East China Normal University, Shanghai, China
| | - Shengbo Huang
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences, School of Life Sciences, East China Normal University, Shanghai, China
| | - Jie Liu
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences, School of Life Sciences, East China Normal University, Shanghai, China
| | - Junqing Gao
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lina Xing
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Putuo Clinical Medical School, Anhui Medical University, Shanghai, China
| | - Zongjun Liu
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Putuo Clinical Medical School, Anhui Medical University, Shanghai, China
- *Correspondence: Zongjun Liu, ; Xin Wang,
| | - Xin Wang
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences, School of Life Sciences, East China Normal University, Shanghai, China
- *Correspondence: Zongjun Liu, ; Xin Wang,
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9
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Best JG, Cardus B, Klijn CJM, Lip G, Seiffge DJ, Smith EE, Werring DJ. Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2020-325249. [PMID: 35728935 DOI: 10.1136/jnnp-2020-325249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
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Affiliation(s)
- Jonathan G Best
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrix Cardus
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital, Bern, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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10
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Yamakawa K. Special Issue on "Disseminated Intravascular Coagulation: Current Understanding and Future Perspectives". J Clin Med 2022; 11:jcm11123315. [PMID: 35743386 PMCID: PMC9225217 DOI: 10.3390/jcm11123315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/08/2022] [Indexed: 12/10/2022] Open
Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan
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11
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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12
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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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13
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Pracoń R, Zieliński K, Bangalore S, Konka M, Kruk M, Kępka C, Trochimiuk P, Dębski M, Przyłuski J, Kaczmarska E, Dzielińska Z, Kurowski A, Witkowski A, Demkow M. Residual stroke risk after left atrial appendage closure in patients with prior oral anticoagulation failure. Int J Cardiol 2022; 354:17-21. [PMID: 35219744 DOI: 10.1016/j.ijcard.2022.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and oral anticoagulation (OAC) failure may benefit from left atrial appendage closure (LAAC), however, the evidence is scarce. We report outcomes of LAAC in patients with OAC failure compared to those with classic indications of OAC contraindications. METHODS Prospective registry of LAAC with Amplatzer or WATCHMAN device followed by dual antiplatelet therapy (DAPT) was analyzed (05.2014-11.2019). The study group included patients with OAC failure defined as stroke/TIA/PE/LAA thrombus (n = 39) during OAC, whereas the control group consisted of patients with OAC contraindications (n = 156). Structured follow-up at 3, 6, and 12 months was done. RESULTS The study group compared to controls was younger [73 (IQR, 62-77) vs 74 (IQR, 68-81) years, P = 0.046], with higher CHA2DS2-VASc [5.0 (IQR, 3.0-6.0) vs 4.0 (IQR, 3.0-5.0), P = 0.001)], lower HAS-BLED [2.0 (IQR, 1.0-3.0) vs 3.0 (IQR, 2.0-3.0), P = 0.006] and similar proportion of WATCHMAN implantations (43.6% vs 44.2%, P = 1.000). The reduction from CHA2DS2-VASc predicted to observed annual stroke/TIA/PE rate was markedly smaller in the study vs control group (14% vs 77%) with 10.3% vs 1.9% stroke/TIA/PE respectively (P = 0.031). The reduction from HAS-BLED predicted to observed annual major nonprocedural bleeding rate was higher (100% vs 7.4%) with 0.0% vs 5.1% major bleedings respectively (P = 0.361). The device-related thrombosis remained similar (13.2% vs 11.3%, P = 0.778). CONCLUSIONS Patients after LAAC for OAC failure and unremarkable prior bleeding history presented with high residual stroke and low bleeding risks. Therefore concomitant long-term OAC or prolonged DAPT should strongly be considered in this population.
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Affiliation(s)
- Radosław Pracoń
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Kamil Zieliński
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland.
| | | | - Marek Konka
- Congenital Cardiac Defects Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Kruk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Cezary Kępka
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Trochimiuk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Dębski
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Jakub Przyłuski
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Edyta Kaczmarska
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Zofia Dzielińska
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Andrzej Kurowski
- Anesthesiology Department, National Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Interventional Cardiology and Angiology Department, National Institute of Cardiology, Warsaw, Poland
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
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14
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Fastner C, Szabo K, Samartzi M, Kruska M, Akin I, Platten M, Baumann S, Alonso A. Treatment standards for direct oral anticoagulants in patients with acute ischemic stroke and non-valvular atrial fibrillation: A survey among German stroke units. PLoS One 2022; 17:e0264122. [PMID: 35176109 PMCID: PMC8853580 DOI: 10.1371/journal.pone.0264122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) in patients with non-valvular atrial fibrillation (AF) despite oral anticoagulation (OAC) is a complex and insufficiently investigated setting. Potential strategies range from maintaining the current OAC to changing the substance class. We have queried the specific treatment standards on German stroke units (SUs). METHODS By means of a standardized online questionnaire via SurveyMonkey™ (San Mateo, CA, USA), all clinical heads of German SUs were asked about their treatment standards in the following clinical situations: first AIS of an OAC-naïve AF patient, AF patient with AIS despite administration of a vitamin K antagonist (VKA), AF patient with AIS despite administration of direct OAC (DOAC). In addition, the performance of specific coagulation tests in AF patients with AIS despite OAC was queried. RESULTS 160 (48%) clinical heads of German SU responded. Data from pivotal trials (84%), own experience with substances (71%), and side-effect profiles (66%) determine the initial DOAC prescription. In case of an AIS despite OAC, 83 and 18% would switch from VKA to DOAC under certain conditions and always, respectively. Half of respondents would switch from DOAC to VKA under certain conditions, while the other half would decline. 96% would switch to an alternative DOAC. The vast majority of those who made preconditions considered concomitant diseases (92, 90, and 81%, respectively). Few would consider infarct pattern (<35%). 61% perform initial coagulation tests (only one-third substance-specific assessments); however, the majority do not use these to make further decisions. CONCLUSIONS In the setting of an OAC-naïve AF patient with AIS, established pivotal data are most respected. In the unclear setting of an AIS despite OAC, most respondents consider concomitant diseases and give preference to switching to a (different) DOAC.
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Affiliation(s)
- Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, University Medical Centre Mannheim, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Melina Samartzi
- Department of Neurology, University Medical Centre Mannheim, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mathieu Kruska
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, University Medical Centre Mannheim, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Baumann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Angelika Alonso
- Department of Neurology, University Medical Centre Mannheim, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Siepen BM, Seiffge DJ, Fischer U. Anticoagulation after stroke: persistent uncertainties. Curr Opin Neurol 2022; 35:55-61. [PMID: 34812748 DOI: 10.1097/wco.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOAC) are the mainstay of anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation. Persistent uncertainties remain in different areas, and this review discusses current dilemmas based on selected studies. RECENT FINDINGS Optimal timing of DOAC initiation after a recent ischaemic stroke in patients with atrial fibrillation is currently unknown and subject of ongoing randomized controlled trials. Ischaemic stroke despite anticoagulant therapy in patients with atrial fibrillation is frequent, constitutes heterogeneous causes (competing stroke cause, medication error and cardioembolism despite anticoagulation) and optimal treatment is currently unknown. Thorough etiological work-up is justified. Recent randomized controlled trials found no beneficial effect of DOAC therapy in unselected patients with embolic stroke of undetermined source (ESUS). Currently ongoing trials targeting subgroup of ESUS patients with additional atrial cardiopathy will provide novel data. Cerebral mircobleeds combined in a novel risk score (MICON score) provide good predictive value to stratify the risk of intracranial haemorrhage in patients taking anticoagulants. Use of DOAC after intracerebral haemorrhage in patients with atrial fibrillation is subject of ongoing trials. SUMMARY There are still significant uncertainties in anticoagulant management in patients with stroke. Ongoing trials will soon provide novel data to improve management of these patients.
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Affiliation(s)
- Bernhard M Siepen
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Graduate School of Health Sciences, University of Bern, Bern
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland
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16
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Ding WY. Residual Stroke Risk in Atrial Fibrillation. Arrhythm Electrophysiol Rev 2021; 10:147-153. [PMID: 34777818 PMCID: PMC8576486 DOI: 10.15420/aer.2021.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/22/2021] [Indexed: 12/16/2022] Open
Abstract
AF contributes to increased stroke risk via various mechanisms, including deranged blood constituents, vessel wall abnormalities and abnormal blood flow. This excess risk is frequently managed with anticoagulation therapy, aimed at preventing thromboembolic complications. Yet, a significant proportion of patients with AF remain at high residual stroke risk despite receiving appropriate dose-adjusted anticoagulation. This article explores the residual stroke risk in AF and potential therapeutic options for these patients.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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17
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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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18
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Stretz C, Wu TY, Wilson D, Seiffge DJ, Smith EE, Gurol ME, Yaghi S. Ischaemic stroke in anticoagulated patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2021; 92:1164-1172. [PMID: 34446528 DOI: 10.1136/jnnp-2020-323963] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023]
Abstract
Anticoagulation substantially reduces the risk of stroke in patients with atrial fibrillation (AF). However, recent studies have shown that up to 22%-36% of patients on anticoagulation will suffer an ischaemic stroke (IS). In this narrative review, we provide an overview of risk factors, mechanisms, management of acute IS and strategies for secondary prevention for patients with AF with stroke despite oral anticoagulation. For this paper, we reviewed available literature from important studies (randomised clinical trials, meta-analyses, reviews and case series) on patients with IS despite anticoagulation. We focused on recent studies that examined safety and efficacy of acute stroke treatments and evaluation and management strategies for secondary prevention. The literature review suggests that patients with AF with IS despite anticoagulation are a heterogeneous group with several possible mechanisms, which may include reduced or non-adherence to anticoagulation, competing non-cardioembolic stroke aetiologies or cardioembolic mechanisms separate from AF. The identification of one or more possible mechanisms of stroke despite anticoagulation may allow for a more targeted and individualised approach for secondary prevention. There are limited data to guide management in such patients, and strategies to prevent recurrent strokes include strict risk factor control and therapies targeting the most likely stroke mechanism. In cases where AF is suspected to be the culprit, clinical trials are needed to test the safety and efficacy of left atrial appendage occlusion plus anticoagulation versus continued anticoagulation alone.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Duncan Wilson
- Stroke Research Centre, UCL Institute of Neurology, London, UK
| | - David J Seiffge
- Department of Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
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Challenges of Acute Ischemic Stroke Treatment in Orally Anticoagulated Patients via Telemedicine. J Clin Med 2021; 10:jcm10091956. [PMID: 34063203 PMCID: PMC8124234 DOI: 10.3390/jcm10091956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 01/19/2023] Open
Abstract
Background: Managing acute ischemic stroke (AIS) in patients receiving treatment with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs) is difficult and the challenge this poses for stroke telemedicine remains unexplored. Methods: We analyzed data from a random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017. Management of patients suffering AIS with and without prior oral anticoagulation treatment was characterized, including potential vs. actual treatment with intravenous thrombolysis (IVT) and reasons for withholding it. Results: n = 359 patients had suffered an AIS, of whom 63 (17.5%) were under treatment with oral anticoagulants (VKA, n = 24; NOAC, n = 39). Administration of IVT was more common in patients who had not received prior oral anticoagulation treatment (20.3% vs. 3.2%, p < 0.001). NOAC intake was the primary reason for withholding IVT in 37% of orally anticoagulated patients who were found potentially eligible for IVT. Furthermore, patients under oral anticoagulation tended to be transported to the comprehensive stroke center more often (23.8% vs. 13.9%, p = 0.056). Conclusions: AIS in patients on oral anticoagulation treatment is a frequent reason for telestroke consultation, and NOAC intake constitutes an important barrier to administering IVT.
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