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Grosse GM, Hüsing A, Stang A, Kuklik N, Brinkmann M, Nabavi D, Sparenberg P, Weissenborn K, Gröschel K, Royl G, Poli S, Michalski D, Eschenfelder CC, Weimar C, Diener HC. Early or late initiation of dabigatran versus vitamin-K-antagonists in acute ischemic stroke or TIA: The PRODAST study. Int J Stroke 2023; 18:1169-1177. [PMID: 37306492 PMCID: PMC10676026 DOI: 10.1177/17474930231184366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND The optimal timing of initiating or resuming anticoagulation after acute ischemic stroke (AIS) or transient ischemic attack (TIA) in patients with atrial fibrillation (AF) is debated. Dabigatran, a non-vitamin K oral anticoagulant (NOAC), has shown superiority against vitamin K antagonists (VKA) regarding hemorrhagic complications. AIMS In this registry study, we investigated the initiation of dabigatran in the early phase after AIS or TIA. METHODS PRODAST (Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA) is a prospective, multicenter, observational, post-authorization safety study. We recruited 10,039 patients at 86 German stroke units between July 2015 and November 2020. A total of 3,312 patients were treated with dabigatran or VKA and were eligible for the analysis that investigates risks for major hemorrhagic events within 3 months after early (⩽ 7 days) or late (> 7 days) initiation of dabigatran or VKA initiated at any time. Further endpoints were recurrent stroke, ischemic stroke, TIA, systemic embolism, myocardial infarction, death, and a composite endpoint of stroke, systemic embolism, life-threatening bleeding and death. RESULTS Major bleeding event rates per 10,000 treatment days ranged from 1.9 for late administered dabigatran to 4.9 for VKA. Early or late initiation of dabigatran was associated with a lower hazard for major hemorrhages as compared to VKA use. The difference was pronounced for intracranial hemorrhages with an adjusted hazard ratio (HR) of 0.47 (95% confidence interval (CI): 0.10-2.21) for early dabigatran use versus VKA use and an adjusted HR of 0.09 (95% CI: 0.00-13.11) for late dabigatran use versus VKA use. No differences were found between early initiation of dabigatran versus VKA use regarding ischemic endpoints. CONCLUSIONS The early application of dabigatran appears to be safer than VKA administered at any time point with regards to the risk of hemorrhagic complications and in particular for intracranial hemorrhage. This result, however, must be interpreted with caution in view of the low precision of the estimate.
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Affiliation(s)
- Gerrit M Grosse
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Anika Hüsing
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Nils Kuklik
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Marcus Brinkmann
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Center for Clinical Trials Essen, University Hospital Essen, Essen, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | | | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | | | - Christian Weimar
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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Hoyer C, Winzer S, Matthé E, Heinle I, Sandikci V, Nabavi D, Platten M, Puetz V, Szabo K. Current diagnosis and treatment practice of central retinal artery occlusion: results from a survey among German stroke units. Neurol Res Pract 2022; 4:30. [PMID: 35909171 PMCID: PMC9341096 DOI: 10.1186/s42466-022-00193-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency whose optimal management is still under debate and due to the absence of definite guidelines, practice is expected to vary. We aimed to characterize early evaluation as well as acute treatment and diagnostic approaches in German hospitals with a stroke unit (SU). Methods In 07/2021, all 335 certified German SUs were invited to participate in an anonymous online survey endorsed by the German Stroke Society on emergency department care organization, diagnostic procedures, and treatment of patients with unilateral vision loss (UVL) subsequently diagnosed with CRAO. Results One hundred and sixty-three (48.6%) of the 335 eligible centers responded. Most (117/135; 86.7%) stated that UVL patients were treated as an emergency, in 62/138 (44.9%) hospitals according to specific guidelines. First-line evaluation was performed by neurologists in 85/136 (62.5%) hospitals, by ophthalmologists in 43/136 (31.6%) hospitals. Seventy of 135 (51.9%) respondents indicated a lack of on-site ophthalmological expertise. Seventy-four of 129 (57.4%) respondents performed thrombolysis in CRAO and 92/97 (94.8%) stated that patients with CRAO–if admitted to neurology–were treated on a SU. Conclusions Our findings reflect notable heterogeneity in early intrahospital care of CRAO in German SUs but demonstrate a preference for work-up and management as acute stroke by the involved neurologists. Streamlining interdisciplinary emergency evaluation is essential for ongoing and future prospective trials.
Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00193-w.
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Tuetuencue S, Olma M, Kunze C, Krämer M, Dietzel J, Schurig J, Pfeilschifter W, Hamann GF, Büttner T, Heuschmann PU, Kirchhof P, Laufs U, Nabavi D, Röther J, Thomalla G, Veltkamp R, Eckardt KU, Häusler KG, Endres M. Abstract WP214: Levels And Dynamics Of Estimated Glomerular Filtration Rate And Clinical Outcomes In Patients With Stroke Or Tia -
Results Of The Mondafis Trial. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Impaired kidney function increases the risk of vascular events in stroke patients, when assessed by single measurements of serum creatinine and estimated glomerular filtration rate (eGFR). Whether repeated measurements improve risk prediction in acute stroke patients is unknown.
Methods:
The investigator-initiated, prospective, multicenter
Systematic Monitoring for Detection of Atrial Fibrillation in Patients with Acute Ischemic Stroke
study randomized 3,465 acute ischemic stroke patients without known AF to usual diagnostic procedures for detecting AF or an additive Holter-ECG. eGFR was estimated by the CKD-Epi formula. Dynamics of eGFR during hospitalization was categorized as “stable ≥60ml/min”, “rising” (by at least 15% from any baseline value), “falling” (by at least 15% and baseline eGFR≥60ml/min) and “stable <60ml/min”. Recurrent stroke, major bleed, myocardial infarction, and all-cause death within 24 months were assessed as a composite endpoint. We estimated hazard ratios in confounder adjusted models.
Results:
The dynamics of eGFR were available in 1,623 patients. In 1,001 (61.7%) eGFR was “stable≥60ml/min”, in 231 (6.7%) “rising”, in 74 (4.6%) “falling”, and in 317 (19.5%) “stable<60ml/min”. After Adjusting for age, stroke severity, cardiovascular risk factors, and randomization, “falling” (HR 1.79; 95%CI 1.07-2.99) and “stable<60ml/min” eGFR (HR 1.64; 95%CI 1.20-2.24) correlated significantly with the composite endpoint, while only “falling” eGFR was associated with all-cause death (HR 3.12; 95%CI 1.63-5.98).
Conclusions:
Hospitalized ischemic stroke patients with a falling eGFR (of at least 15%, baseline ≥60ml/min) are at similar risk for recurrent vascular events or death and at higher risk for death as stroke patients with constantly reduced kidney function. Repeated estimates of eGFR may therefore improve risk prediction.
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Affiliation(s)
| | - Manuel Olma
- Cntr for Stroke Rsch Berlin, Berlin, Germany
| | | | | | | | | | | | | | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, Univ Würzburg, Germany, Würzburg, Germany
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Tütüncü S, Olma M, Kunze C, Dietzel J, Schurig J, Fiessler C, Malsch C, Haas TE, Dimitrijeski B, Doehner W, Hagemann G, Hamilton F, Honermann M, Jungehulsing GJ, Kauert A, Koennecke HC, Mackert BM, Nabavi D, Nolte CH, Reis JM, Schmehl I, Sparenberg P, Stingele R, Völzke E, Waldschmidt C, Zeise-Wehry D, Heuschmann PU, Endress M, Haeusler KG. Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry. J Neurol 2022; 269:470-480. [PMID: 34718884 PMCID: PMC8739306 DOI: 10.1007/s00415-021-10866-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022]
Abstract
AIMS We aimed to analyze prevalence and predictors of NOAC off-label under-dosing in AF patients before and after the index stroke. METHODS The post hoc analysis included 1080 patients of the investigator-initiated, multicenter prospective Berlin Atrial Fibrillation Registry, designed to analyze medical stroke prevention in AF patients after acute ischemic stroke. RESULTS At stroke onset, an off-label daily dose was prescribed in 61 (25.5%) of 239 NOAC patients with known AF and CHA2DS2-VASc score ≥ 1, of which 52 (21.8%) patients were under-dosed. Under-dosing was associated with age ≥ 80 years in patients on rivaroxaban [OR 2.90, 95% CI 1.05-7.9, P = 0.04; n = 29] or apixaban [OR 3.24, 95% CI 1.04-10.1, P = 0.04; n = 22]. At hospital discharge after the index stroke, NOAC off-label dose on admission was continued in 30 (49.2%) of 61 patients. Overall, 79 (13.7%) of 708 patients prescribed a NOAC at hospital discharge received an off-label dose, of whom 75 (10.6%) patients were under-dosed. Rivaroxaban under-dosing at discharge was associated with age ≥ 80 years [OR 3.49, 95% CI 1.24-9.84, P = 0.02; n = 19]; apixaban under-dosing with body weight ≤ 60 kg [OR 0.06, 95% CI 0.01-0.47, P < 0.01; n = 56], CHA2DS2-VASc score [OR per point 1.47, 95% CI 1.08-2.00, P = 0.01], and HAS-BLED score [OR per point 1.91, 95% CI 1.28-2.84, P < 0.01]. CONCLUSION At stroke onset, off-label dosing was present in one out of four, and under-dosing in one out of five NOAC patients. Under-dosing of rivaroxaban or apixaban was related to old age. In-hospital treatment after stroke reduced off-label NOAC dosing, but one out of ten NOAC patients was under-dosed at discharge. CLINICAL TRIAL REGISTRATION NCT02306824.
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Affiliation(s)
- Serdar Tütüncü
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel Olma
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joanna Dietzel
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelia Fiessler
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Eberhard Haas
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | | | - Wolfram Doehner
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- BCRT-Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Georg Hagemann
- Department of Neurology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Martin Honermann
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | | | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | | | | | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Joschua Mirko Reis
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Ingo Schmehl
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Robert Stingele
- Department of Neurology, German Red Cross Hospital Berlin Köpenick, Berlin, Germany
| | - Enrico Völzke
- Department of Neurology, Schlosspark-Klinik Berlin, Berlin, Germany
| | | | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Endress
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner site Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
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5
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Tütüncü S, Olma M, Kunze C, Dietzel J, Schurig J, Fiessler C, Malsch C, Haas TE, Dimitrijeski B, Doehner W, Hagemann G, Hamilton F, Honermann M, Jungehulsing GJ, Kauert A, Koennecke HC, Mackert BM, Nabavi D, Nolte CH, Reis JM, Schmehl I, Sparenberg P, Stingele R, Völzke E, Waldschmidt C, Zeise-Wehry D, Heuschmann PU, Endres M, Haeusler KG. Correction to: Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry. J Neurol 2021; 269:481-482. [PMID: 34837502 PMCID: PMC8738357 DOI: 10.1007/s00415-021-10907-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Serdar Tütüncü
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel Olma
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joanna Dietzel
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelia Fiessler
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Eberhard Haas
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | | | - Wolfram Doehner
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,BCRT-Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Georg Hagemann
- Department of Neurology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Martin Honermann
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | | | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | | | | | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Joschua Mirko Reis
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Ingo Schmehl
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Robert Stingele
- Department of Neurology, German Red Cross Hospital Berlin Köpenick, Berlin, Germany
| | - Enrico Völzke
- Department of Neurology, Schlosspark-Klinik Berlin, Berlin, Germany
| | | | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner site Berlin, Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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Röther J, Busse O, Berlis A, Dörfler A, Groden C, Hamann G, Jansen O, Meixensberger J, Müller O, Regelsberger J, Steinmetz H, Vatter H, Weber W, Hänggi D, Nabavi D. [Erratum to: Interdisciplinary neurovascular networks: state of the art]. Nervenarzt 2020; 91:1169. [PMID: 33156367 DOI: 10.1007/s00115-020-01016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- J Röther
- Kopf- und Neurozentrum, Neurologische Abteilung mit überregionaler Stroke Unit, Neurophysiologie und Neurologischer Intensivmedizin, Asklepios Klinik Hamburg Altona, Asklepios Campus Hamburg der Semmelweis Universität, Hamburg, Deutschland.
| | - O Busse
- Deutsche Schlaganfall-Gesellschaft, Berlin, Deutschland
| | - A Berlis
- Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklink Augsburg, Augsburg, Deutschland
| | - A Dörfler
- Neuroradiologische Abteilung, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Ch Groden
- Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - G Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg der Bezirkskliniken Schwaben, Günzburg, Deutschland
| | - O Jansen
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - J Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - O Müller
- Klinik für Neurochirurgie, Klinikum Dortmund, Dortmund, Deutschland
| | - J Regelsberger
- Neurochirurgische Klinik, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | - H Steinmetz
- Klinik für Neurologie, Universitätsklinikum, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - H Vatter
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - W Weber
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie und Nuklearmedizin, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Deutschland
| | - D Hänggi
- Neurochirurgische Klinik/Department of Neurosurgery, Universitätsklinikum Düsseldorf/Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - D Nabavi
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Berlin, Deutschland
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Haeusler KG, Tütüncü S, Kunze C, Schurig J, Malsch C, Harder J, Wiedmann S, Dimitrijeski B, Ebinger M, Hagemann G, Hamilton F, Honermann M, Jungehulsing GJ, Kauert A, Koennecke HC, Leithner C, Mackert BM, Masuhr F, Nabavi D, Rocco A, Schmehl I, Schmitz B, Sparenberg P, Stingele R, von Brevern M, Völzke E, Dietzel J, Heuschmann PU, Endres M. Oral anticoagulation in patients with atrial fibrillation and acute ischaemic stroke: design and baseline data of the prospective multicentre Berlin Atrial Fibrillation Registry. Europace 2020; 21:1621-1632. [PMID: 31397475 DOI: 10.1093/europace/euz199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/28/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS The Berlin Atrial Fibrillation Registry was designed to analyse oral anticoagulation (OAC) prescription in patients with atrial fibrillation (AF) and acute ischaemic stroke. METHODS AND RESULTS This investigator-initiated prospective multicentre registry enrolled patients at all 16 stroke units located in Berlin, Germany. The ongoing telephone follow-up is conducted centrally and will cover 5 years per patient. Within 2014 and 2016, 1080 patients gave written informed consent and 1048 patients were available for analysis. Median age was 77 years [interquartile range (IQR) 72-83], 503 (48%) patients were female, and 254 (24%) had a transient ischaemic attack (TIA). Overall, 470 (62%) out of 757 patients with known AF and a (pre-stroke) CHA2DS2-VASc ≥ 1 were anticoagulated at the time of stroke. At hospital discharge, 847 (81.3%) of 1042 patients were anticoagulated. Thereof 710 (68.1%) received a non-vitamin K-dependent oral anticoagulant (NOAC) and 137 (13.1%) a vitamin K antagonist (VKA). Pre-stroke intake of a NOAC [odds ratio (OR) 15.6 (95% confidence interval, 95% CI 1.97-122)] or VKA [OR 0.04 (95% CI 0.02-0.09)], an index TIA [OR 0.56 (95% CI 0.34-0.94)] rather than stroke, heart failure [OR 0.49 (95% CI 0.26-0.93)], and endovascular thrombectomy at hospital admission [OR 12.9 (95% CI 1.59-104)] were associated with NOAC prescription at discharge. Patients' age or AF type had no impact on OAC or NOAC use, respectively. CONCLUSION About 60% of all registry patients with known AF received OAC at the time of stroke or TIA. At hospital discharge, more than 80% of AF patients were anticoagulated and about 80% of those were prescribed a NOAC.
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Affiliation(s)
- Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, Würzburg, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Clinical Trial Centre Würzburg, University Hospital Würzburg, Germany
| | - Janek Harder
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany
| | - Silke Wiedmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Strategic Corporate Development, Charité-Universitätsmedizin Berlin, Germany
| | | | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georg Hagemann
- Department of Neurology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Martin Honermann
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | - Gerhard Jan Jungehulsing
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Jüdisches Krankenhaus Berlin, Germany
| | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | | | | | | | - Florian Masuhr
- Department of Neurology, Bundeswehrkrankenhaus Berlin, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Andrea Rocco
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Ingo Schmehl
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Germany
| | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Germany
| | - Robert Stingele
- Department of Neurology, German Red Cross Hospital Berlin, Köpenick, Germany
| | | | - Enrico Völzke
- Department of Neurology, Schlosspark-Klinik Berlin, Germany
| | - Joanna Dietzel
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Clinical Trial Centre Würzburg, University Hospital Würzburg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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8
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Röther J, Busse O, Berlis A, Dörfler A, Groden C, Hamann G, Jansen O, Meixensberger J, Müller O, Regelsberger J, Steinmetz H, Vatter H, Weber W, Hänggi D, Nabavi D. [Interdisciplinary neurovascular networks: state of the art]. Nervenarzt 2020; 91:902-907. [PMID: 32930814 DOI: 10.1007/s00115-020-00991-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of a coordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. OBJECTIVE How efficient are the NVN? Are high standards maintained? MATERIAL AND METHODS The reports of the audits were analyzed. The data were taken from the period 2017-2019. RESULTS The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. CONCLUSION The certification process of NVN has been successfully established and the audits proved to be a useful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.
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Affiliation(s)
- J Röther
- Kopf- und Neurozentrum, Neurologische Abteilung mit überregionaler Stroke Unit, Neurophysiologie und Neurologischer Intensivmedizin, Asklepios Klinik Hamburg Altona, Asklepios Campus Hamburg der Semmelweis Universität, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland.
| | - O Busse
- Deutsche Schlaganfall-Gesellschaft, Reinhardtstraße 27C, 10117, Berlin, Deutschland
| | - A Berlis
- Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklink Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - A Dörfler
- Neuroradiologische Abteilung, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6 (Kopfkliniken), 91054, Erlangen, Deutschland
| | - Ch Groden
- Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - G Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg der Bezirkskliniken Schwaben, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Deutschland
| | - O Jansen
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller Str. 3, 24105, Kiel, Deutschland
| | - J Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - O Müller
- Klinik für Neurochirurgie, Klinikum Dortmund, Münsterstr. 240, 44145, Dortmund, Deutschland
| | - J Regelsberger
- Neurochirurgische Klinik, Universitätsklinikum Hamburg Eppendorf, Martinistr 52, 20251, Hamburg, Deutschland
| | - H Steinmetz
- Klinik für Neurologie, Universitätsklinikum, Goethe-Universität Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - H Vatter
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - W Weber
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie und Nuklearmedizin, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - D Hänggi
- Neurochirurgische Klinik / Department of Neurosurgery, Universitätsklinikum Düsseldorf / Düsseldorf University Hospital, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - D Nabavi
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland
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9
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Norrving B, Barrick J, Davalos A, Dichgans M, Cordonnier C, Guekht A, Kutluk K, Mikulik R, Wardlaw J, Richard E, Nabavi D, Molina C, Bath PM, Stibrant Sunnerhagen K, Rudd A, Drummond A, Planas A, Caso V. Action Plan for Stroke in Europe 2018-2030. Eur Stroke J 2018; 3:309-336. [PMID: 31236480 PMCID: PMC6571507 DOI: 10.1177/2396987318808719] [Citation(s) in RCA: 241] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg
meetings, were convened to review the scientific evidence and the state of
current services to identify priorities for research and development and to set
targets for the development of stroke care for the decade to follow. Adhering to
the same format, the European Stroke Organisation (ESO) prepared a European
Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the
Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary
prevention, organisation of stroke services, management of acute stroke,
secondary prevention, rehabilitation, evaluation of stroke outcome and quality
assessment and life after stroke. Research priorities for translational stroke
research were also identified. Documents were prepared by a working group and
were open to public comments. The final document was prepared after a workshop
in Munich on 21–23 March 2018. Four overarching targets for 2030 were
identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2)
to treat 90% or more of all patients with stroke in Europe in a dedicated stroke
unit as the first level of care, (3) to have national plans for stroke
encompassing the entire chain of care, (4) to fully implement national
strategies for multisector public health interventions. Overall, 30 targets and
72 research priorities were identified for the seven domains. The ESAP provides
a basic road map and sets targets for the implementation of evidence-based
preventive actions and stroke services to 2030.
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Affiliation(s)
- Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Antoni Davalos
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians University, Munich, and Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | | | - Alla Guekht
- Clinical Center for Neuropsychiatry, Russian National Research Medical University, Moscow, Russia
| | - Kursad Kutluk
- Department of Neurology, Stroke Unit, University of Dokuz Eylul, Izmir, Turkey
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's University Hospital Brno and Masaryk University Brno, Czech Republic
| | - Joanna Wardlaw
- Centre for Clinical Neurosciences, Edinburgh Imaging and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Edo Richard
- Department of Neurology, Radboud University Medical Centre, Nijmegen, and Department of Neurology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Darius Nabavi
- Department of Neurology with Stroke Unit, Vivantes Hospital Neukölln, Berlin, Germany
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Hospital Vall d´Hebron Barcelona, Spain
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Anthony Rudd
- Guy's and St Thomas' NHS Foundation Trust, Stroke NHS England and Royal College of Physicians, London, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anna Planas
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Valeria Caso
- Stroke Unit, Department of Medicine and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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10
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Nabavi D, Ossenbrink M, Busse O. Qualitätsmanagement in der Stroke Unit. Akt Neurol 2018. [DOI: 10.1055/a-0642-1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
ZusammenfassungQualitätsmanagement (QM) ist ein gesetzlich vorgeschriebenes strukturelles Element für Krankenhäuser in Deutschland. Zwar ist das Bestreben nach Qualitätsverbesserungen fester Bestandteil der Medizin, der formale QM-Ansatz wird in der Ärzteschaft dennoch bis heute kontrovers betrachtet. Aufgrund zeitkritischer Aspekte, risikobehafteter Therapiemaßnahmen und der interdisziplinären Herangehensweise besteht zweifelsfrei eine QM-Rationale für die Schlaganfallmedizin. Durch das in Deutschland bereits seit Mitte der 90er Jahre etablierte Zertifizierungsverfahren von Stroke Units (SU) werden qualitative Mindeststandards regelmäßig überprüft und QM-Maßnahmen verbindlich eingefordert. Dies umfasst die gesamte Versorgungskette vom prähospitalen Initialmanagement bis hin zum poststationären Konzept. Allerdings darf die Erlangung eines Zertifikates allein nicht als Endpunkt eines erfolgreichen QM betrachtet werden. Das fortlaufende Bemühen um Qualitätsverbesserungen setzt eine Haltung voraus, die von der Führungsebene glaubhaft vermittelt und in der gesamten Abteilung fest verankert sein muss. Insgesamt stellt die Entwicklung der Schlaganfallmedizin in Deutschland ein überzeugendes Beispiel für gelungenes QM dar.
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Affiliation(s)
- Darius Nabavi
- Neurologie, Vivantes Klinikum Neukölln, Berlin; Vorsitzender der Stroke Unit-Kommission der Deutschen Schlaganfallgesellschaft
| | | | - Otto Busse
- Vorsitzender des Zertifizierungsausschusses, Deutsche Schlaganfallgesellschaft, Berlin
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11
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Häusler K, Gröschel K, Köhrmann M, Schnabel R, Anker S, Brachmann J, Böhm M, Diener HC, Doehner W, Endres M, Gerloff C, Huttner H, Kaps M, Kirchhof P, Nabavi D, Nolte C, Pfeilschifter W, Pieske B, Poli S, Schäbitz W, Thomalla G, Veltkamp R, Steiner T, Laufs U, Röther J, Wachter R. Positionspapier zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall. Akt Neurol 2017. [DOI: 10.1055/s-0043-118476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDas vorliegende Positionspapier zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall beinhaltet eine Stellungnahme der Arbeitsgemeinschaft „Herz und Hirn“ der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK) und der Deutschen Schlaganfallgesellschaft e. V. (DSG), die in Zusammenarbeit mit der Stroke Unit-Kommission der DSG und dem Kompetenznetz Vorhofflimmern (AFNET) e. V. erstellt wurde.Vorhofflimmern ist in den Leitlinien der Europäischen Gesellschaft für Kardiologie als eine mindestens 30 Sekunden anhaltende Episode einer Vorhofarrhythmie mit fehlenden P-Wellen definiert. Die 30-Sekundengrenze ist arbiträr gewählt und es ist unbekannt, ob das Schlaganfallrisiko bei Episoden von länger als 30 Sekunden höher ist als bei kürzeren Episoden. Bei Patienten, die einen Schlaganfall erlitten haben, sollte die Detektion von Vorhofflimmern üblicherweise zu einer Umstellung der medikamentösen Sekundärprävention führen, da eine orale Antikoagulation einer Thrombozytenaggregationshemmung überlegen ist. Die Detektion eines bis dato nicht diagnostizierten Vorhofflimmerns sollte daher bei Patienten mit ischämischem Schlaganfall verbessert werden, um die medikamentöse Sekundärprävention des Schlaganfalls zu optimieren. In diesem Positionspapier werden interdisziplinär erarbeitete Standards für eine „strukturierte Rhythmusvisite“ auf der Stroke Unit und ein diagnostisches „Stufenschema“ zur Detektion von Vorhofflimmern vorgeschlagen. Das Positionspapier fasst zudem den gegenwärtigen Kenntnisstand zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall zusammen. Das Positionspapier soll den in der Versorgung von Schlaganfallpatienten tätigen Ärzten eine Handhabe geben, auch wenn bisher nicht abschließend geklärt ist, wie lange und mit welcher EKG-Methode Schlaganfallpatienten ohne bisher bekannte Herzrhythmusstörung bestmöglich monitoriert werden sollten. Dem Charakter eines Positionspapiers angemessen, wurde auf die Kennzeichnung von Evidenzgraden verzichtet, da es sich überwiegend um die Meinung von Experten handelt, die auf berichteten Fallserien und klinischer Erfahrung beruht und somit nicht mit einer Leitlinie gleichzusetzen ist und so auch nicht verstanden werden will.
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Affiliation(s)
- Karl Häusler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin
- Centrum für Schlaganfallforschung Berlin, Charité – Universitätsmedizin Berlin
- Kompetenznetz Vorhofflimmern e.V
| | - Klaus Gröschel
- Klinik und Poliklinik für Neurologie, Universitätsmedizin Mainz, Mainz
| | | | - Renate Schnabel
- Kompetenznetz Vorhofflimmern e.V
- Abteilung für Allgemeine und Interventionelle Kardiologie, Universitäres Herzzentrum Hamburg
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), Standort Hamburg/Kiel/Lübeck
| | - Stefan Anker
- Abteilung Kardiologie und Stoffwechsel – Herzinsuffizienz, Kachexie & Sarcopenie, Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité – Universitätsmedizin Berlin
- Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen (UMG) & Deutsches Zentrum für Kardiovaskuläre Forschung (DZHK), Standort Berlin
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg
| | | | - Wolfram Doehner
- Centrum für Schlaganfallforschung Berlin, Charité – Universitätsmedizin Berlin
- Klinik für Innere Medizin mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Berlin, Charité – Universitätsmedizin Berlin
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin
- Centrum für Schlaganfallforschung Berlin, Charité – Universitätsmedizin Berlin
- Berlin Institute of Health
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), Standort Berlin
- Deutsches Zentrum für Degenerative Erkrankungen (DZNE), Standort Berlin
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Eppendorf, Hamburg
- Stroke Unit Kommission der Deutschen Schlaganfall-Gesellschaft
| | - Hagen Huttner
- Neurologische Klinik, Universitätsklinikum Erlangen, Erlangen
| | - Manfred Kaps
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Gießen
| | - Paulus Kirchhof
- Kompetenznetz Vorhofflimmern e.V
- Institute of Cardiovascular Sciences, University of Birmingham, Sandwell and West Birmingham Hospitals NHS trust, University Hospitals Birmingham NHS Foundation NHS trust, Birmingham, Großbritannien
| | - Darius Nabavi
- Stroke Unit Kommission der Deutschen Schlaganfall-Gesellschaft
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Berlin
| | - Christian Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin
- Centrum für Schlaganfallforschung Berlin, Charité – Universitätsmedizin Berlin
- Berlin Institute of Health
| | - Waltraud Pfeilschifter
- Zentrum der Neurologie und Neurochirurgie, Klinik für Neurologie, Universitätsklinikum Frankfurt
| | - Burkert Pieske
- Klinik für Innere Medizin mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Berlin, Charité – Universitätsmedizin Berlin
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), Standort Berlin
- Klinik für Innere Medizin und Kardiologie, Deutsches Herzzentrum Berlin
| | - Sven Poli
- Abteilung Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen und Hertie-Institut für klinische Hirnforschung, Universitätsklinikum Tübingen, Tübingen
| | - Wolf Schäbitz
- Klinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Eppendorf, Hamburg
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, Großbritannien
| | - Thorsten Steiner
- Neurologische Klinik, Klinikum Frankfurt Höchst, Frankfurt
- Neurologische Klinik, Universitätsklinik Heidelberg, Heidelberg
| | - Ulrich Laufs
- Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig
| | - Joachim Röther
- Abteilung für Neurologie, Asklepios Klinik Altona, Hamburg
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig
- Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen & Deutsches Zentrum Herz-Kreislauf-Forschung e.V., Standort Göttingen
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12
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Ulm L, Hoffmann S, Nabavi D, Hermans M, Mackert BM, Hamilton F, Schmehl I, Jungehuelsing GJ, Montaner J, Bustamante A, Katan M, Hartmann A, Ebmeyer S, Dinter C, Wiemer JC, Hertel S, Meisel C, Anker SD, Meisel A. The Randomized Controlled STRAWINSKI Trial: Procalcitonin-Guided Antibiotic Therapy after Stroke. Front Neurol 2017; 8:153. [PMID: 28484421 PMCID: PMC5402305 DOI: 10.3389/fneur.2017.00153] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/03/2017] [Indexed: 11/17/2022] Open
Abstract
Background Pneumonia is among the most common acute complications after stroke and is associated with poor long-term outcome. Biomarkers may help identifying stroke patients at high risk for developing stroke-associated pneumonia (SAP) and to guide early treatment. Aims This trial investigated whether procalcitonin (PCT) ultrasensitive (PCTus)-guided antibiotic treatment of SAP can improve functional outcome after stroke. Methods In this international, multicenter, randomized, controlled clinical trial with blinded assessment of outcomes, patients with severe ischemic stroke in the middle cerebral artery territory were randomly assigned within 40 h after symptom onset to PCTus-based antibiotic therapy guidance in addition to stroke unit care or standard stroke unit care alone. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale (mRS) and dichotomized as acceptable (≤4) or unacceptable (≥5). Secondary endpoints included usage of antibiotics, infection rates, days of fever, and mortality. The trial was registered with http://ClinicalTrials.gov (Identifier NCT01264549). Results In the intention-to-treat-analysis based on 227 patients (112 in PCT and 115 in control group), 197 patients completed the 3-month follow-up. Adherence to PCT guidance was 65%. PCT-guided therapy did not improve functional outcome as measured by mRS (odds ratio 0.79; 95% confidence interval 0.45–1.35, p = 0.47). Pneumonia rate and mortality were similar in both groups. Days with fever tended to be lower (p = 0.055), whereas total number of days treated with antibiotics were higher (p = 0.004) in PCT compared to control group. A post hoc analysis including all PCT values in the intention-to-treat population demonstrated a significant increase on the first day of infection in patients with pneumonia and sepsis compared to patients with urinary tract infections or without infections (p < 0.0001). Conclusion PCTus-guided antibiotic therapy did not improve functional outcome at 3 months after severe ischemic stroke. PCT is a promising biomarker for early detection of pneumonia and sepsis in acute stroke patients.
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Affiliation(s)
- Lena Ulm
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Sarah Hoffmann
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | - Marcella Hermans
- Department of Neurology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | | | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Ingo Schmehl
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Gerhard-Jan Jungehuelsing
- Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology, Juedisches Krankenhaus Berlin, Berlin, Germany
| | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mira Katan
- Department of Neurology, Universitaetsspital Zuerich, Zurich, Switzerland
| | - Andreas Hartmann
- Department of Neurology, Klinikum Frankfurt Oder, Frankfurt Oder, Germany
| | - Stefan Ebmeyer
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | | | - Jan C Wiemer
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | - Sabine Hertel
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | - Christian Meisel
- Department of Immunology, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Stefan D Anker
- Division of Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Goettingen, Goettingen, Germany.,Centre for Clinical and Basic Research, IRCCS, Rome, Italy
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
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13
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Hillmann S, Wiedmann S, Rücker V, Berger K, Nabavi D, Bruder I, Koennecke HC, Seidel G, Misselwitz B, Janssen A, Burmeister C, Matthis C, Busse O, Hermanek P, Heuschmann PU. Stroke unit care in germany: the german stroke registers study group (ADSR). BMC Neurol 2017; 17:49. [PMID: 28279162 PMCID: PMC5343401 DOI: 10.1186/s12883-017-0819-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/10/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Factors influencing access to stroke unit (SU) care and data on quality of SU care in Germany are scarce. We investigated characteristics of patients directly admitted to a SU as well as patient-related and structural factors influencing adherence to predefined indicators of quality of acute stroke care across hospitals providing SU care. METHODS Data were derived from the German Stroke Registers Study Group (ADSR), a voluntary network of 9 regional registers for monitoring quality of acute stroke care in Germany. Multivariable logistic regression analyses were performed to investigate characteristics influencing direct admission to SU. Generalized Linear Mixed Models (GLMM) were used to estimate the influence of structural hospital characteristics (percentage of patients admitted to SU, year of SU-certification, and number of stroke and TIA patients treated per year) on adherence to predefined quality indicators. RESULTS In 2012 180,887 patients were treated in 255 hospitals providing certified SU care participating within the ADSR were included in the analysis; of those 82.4% were directly admitted to a SU. Ischemic stroke patients without disturbances of consciousness (p < .0001), an interval onset to admission time ≤3 h (p < .0001), and weekend admission (p < .0001) were more likely to be directly admitted to a SU. A higher proportion of quality indicators within predefined target ranges were achieved in hospitals with a higher proportion of SU admission (p = 0.0002). Quality of stroke care could be maintained even if certification was several years ago. CONCLUSIONS Differences in demographical and clinical characteristics regarding the probability of SU admission were observed. The influence of structural characteristics on adherence to evidence-based quality indicators was low.
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Affiliation(s)
- Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany.
| | - Silke Wiedmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Straubmühlweg 2a, 97078, Würzburg, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
| | - Klaus Berger
- Quality Assurance Project"Stroke Register Northwest Germany", Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Gebäude D3, 48149, Münster, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Rudower Straße 48, 12351, Berlin, Germany
| | - Ingo Bruder
- Office for Quality Assurance in Hospitals (GeQiK) Stuttgart at Baden-Wuerttembergische Hospital Federation, Stuttgart, Birkenwaldstr. 151, 70191, Stuttgart, Germany
| | | | - Günter Seidel
- Department of Neurology, Asklepios Klinik Nord, Hamburg,, Tangstedter Landstraße 400, 22417, Hamburg, Germany
| | - Björn Misselwitz
- Institute of Quality Assurance Hesse (GQH), Frankfurter Str. 10, 65760, Eschborn, Germany
| | - Alfred Janssen
- Quality Assurance in Stroke Management in North Rhine-Westphalia, Medical Association North Rhine, Tersteegenstr. 9, 40474, Düsseldorf, Germany
| | - Christoph Burmeister
- Institute of Quality Assurance Rhineland-Palatinate / SQMed, Wilhelm-Theodor-Römheld-Straße 34, 55130, Mainz, Germany
| | - Christine Matthis
- Quality Association for Acute Stroke Treatment Schleswig-Holstein (QugSS), Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Otto Busse
- German Stroke Society, Berlin, Reinhardtstr. 27C, 10117, Berlin, Germany
| | - Peter Hermanek
- Bavarian Permanent Working Party for Quality Assurance, Munich, Westenriederstr. 19, 80331, Munich, Germany
| | - Peter Ulrich Heuschmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Straubmühlweg 2a, 97078, Würzburg, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
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Häusler KG, Heuschmann PU, Kirchhof P, Laufs U, Nabavi D, Röther J, Veltkamp R, Endres M. [Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke]. Dtsch Med Wochenschr 2015; 140 Suppl 1:S5-6. [PMID: 26069047 DOI: 10.1055/s-0041-101292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Karl Georg Häusler
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin
| | - Peter U Heuschmann
- Institut für Klinische Epidemiologie und Biometrie, Julius-Maximilians Universität Würzburg
| | - Paulus Kirchhof
- Centre for Cardiovascular Science, University of Birmingham, UK
| | - Ulrich Laufs
- Kardiologie, Klinik für Innere Medizin III, Homburg / Saar
| | - Darius Nabavi
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Berlin
| | | | | | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin
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15
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Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D, Horn M, Weimar C, Köhrmann M, Wachter R, Rosin L, Kirchhof P. Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke. Stroke 2013; 44:3357-64. [DOI: 10.1161/strokeaha.113.001884] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Adequate diagnosis of atrial fibrillation (AF), including paroxysmal AF, is an important part of stroke workup. Prolonged ECG monitoring may improve the detection of paroxysmal, previously undiagnosed AF (unknown AF). Therefore, we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke.
Methods—
Unselected survivors of a stroke or transient ischemic attack (TIA) without known AF were enrolled in a prospective, multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011. In addition to standardized workup of stroke pathogenesis according to the German Stroke Unit protocol, all patients underwent 72-hour Holter ECG monitoring directly after admission. All ECGs were centrally analyzed by 2 independent observers. We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring.
Results—
A total of 1135 patients were enrolled (mean age, 67 years [SD, 13.1 years], 45% women, 29% TIA). Unknown AF was detected in 49 out of 1135 patients (4.3%, [95% confidence interval, 3.4–5.2%]) by 72-hour ECG monitoring. Unknown AF was diagnosed in 29 patients (2.6%) within the first 24 hours of ECG monitoring, and in 20 more patients only by 72 hours of ECG monitoring. The number needed to screen by 72-hour ECG was 55 patients (95% confidence interval [35–123]) for each additional AF diagnosis. Patients with unknown AF were significantly older and had more often a history of previous stroke. Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification.
Conclusions—
In unselected survivors of stroke or TIA, 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF.
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Affiliation(s)
- Martin Grond
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Marek Jauss
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Gerhard Hamann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Erwin Stark
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Roland Veltkamp
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Darius Nabavi
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Markus Horn
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Christian Weimar
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Martin Köhrmann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Rolf Wachter
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Ludger Rosin
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Paulus Kirchhof
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
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Affiliation(s)
- M. Ritter
- Klinik und Poliklinik für Neurologie (Direktor: Univ.-Prof. Dr. med. E. Bernd Ringelstein), Universitätsklinikum Münster
| | - R. Dittrich
- Klinik und Poliklinik für Neurologie (Direktor: Univ.-Prof. Dr. med. E. Bernd Ringelstein), Universitätsklinikum Münster
| | - O. Busse
- Generalsekretär der Deutschen Schlaganfallgesellschaft, Berlin
| | - D. Nabavi
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Berlin
| | - E. Ringelstein
- Klinik und Poliklinik für Neurologie (Direktor: Univ.-Prof. Dr. med. E. Bernd Ringelstein), Universitätsklinikum Münster
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Nabavi D, Sliwka U. Mikroembolusdetektion mittels transkranieller Dopplersonographie. KLIN NEUROPHYSIOL 2008. [DOI: 10.1055/s-2008-1060108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Kuhlenbäumer G, Friedrichs F, Kis B, Berlit P, Maintz D, Nassenstein I, Nabavi D, Dittrich R, Stoll M, Ringelstein B. Association between single nucleotide polymorphisms in the lysyl oxidase-like 1 gene and spontaneous cervical artery dissection. Cerebrovasc Dis 2007; 24:343-8. [PMID: 17690546 DOI: 10.1159/000106980] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Accepted: 04/13/2007] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Spontaneous cervical artery dissection (sCAD) is a common cause of stroke in patients below 55 years. Dermal connective tissue abnormalities have been observed in up to 60% of patients. A chromosomal locus for connective tissue abnormalities associated with sCAD has been mapped to chromosome 15q24 to a candidate region containing the lysyl oxidase-like 1 gene (LOXL1). LOXL1 an excellent candidate susceptibility gene for non-familial sCAD was investigated by mutation analysis and a genetic association study. METHODS We sequenced the whole coding region of the LOXL1 gene in 15 sCAD patients and performed a genetic association study in 157 sCAD patients using 12 single nucleotide polymorphisms (SNP). RESULTS The SNP rs3825942 (Gly153Asp) showed marginal association with sCAD on an allele basis and in the dominant genetic model, and intronic SNP rs893817 under a recessive model only. None of the SNP haplotypes was associated with sCAD. CONCLUSIONS Genetic variation in LOXL1 might play a role as a risk factor for sCAD.
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Affiliation(s)
- G Kuhlenbäumer
- Leibniz Institute of Atherosclerosis Research, University of Münster, Münster, Germany.
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Allroggen A, Prugger C, Wefers K, Weber T, Schilling M, Heuschmann P, Nabavi D. Vergleich zwischen der prähospitalen Los Angeles Schlaganfallskala und des Gesicht-, Arm- und Sprachtests zur Schlaganfallerkennung durch Rettungsassistenten. Akt Neurol 2007. [DOI: 10.1055/s-2007-987938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Crome O, Schönborn H, Reuter M, Jödicke A, Kretzschmar H, Zerr I, van Landeghem F, Nabavi D. Progressive Demenz mit Aphasie und passagerer Quadrantenanopsie – Variante einer sporadischen Creuztfeld-Jakob-Erkrankung. Akt Neurol 2007. [DOI: 10.1055/s-2007-987949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
We report on a female patient with brachioradial pruritus, in whom the cause could be verified by purposeful diagnostics (e. g., MRI). The clinical symptoms with localized itching result from circumscribed nerve root compression and hyperexcitation of the nerve fibers. Under treatment with gabapentin, an anticonvulsant with a very good analgesic and good antipruritic effect, the itch ceased and the skin changes healed. This case shows that this special form of neuropathic itch requires targeted therapy, which apart from symptomatic treatment should primarily focus on remedying the cause, if feasible.
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Kuhlenbäumer G, Konrad C, Krämer S, Kis B, Nabavi D, Dittrich R, Ringelstein EB. The collagen 1A2 polymorphism rs42524, which is associated with intracranial aneurysms, shows no association with spontaneous cervical artery dissection (sCAD). J Neurol Neurosurg Psychiatry 2006; 77:124-5. [PMID: 16361613 PMCID: PMC2117412 DOI: 10.1136/jnnp.2005.065847] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Schneider G, Nabavi D, Heuft G. Eye movement desensitization and reprocessing in the treatment of posttraumatic stress disorder in a patient with comorbid epilepsy. Epilepsy Behav 2005; 7:715-8. [PMID: 16246634 DOI: 10.1016/j.yebeh.2005.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 08/17/2005] [Accepted: 08/20/2005] [Indexed: 11/28/2022]
Abstract
Whether eye movement desensitization and reprocessing (EMDR) treatment of posttraumatic stress disorder (PTSD) causes reactivation of epilepsy is as yet unclear. A 34-year-old woman was treated in an inpatient multimodal psychotherapeutic setting with EMDR for PTSD resulting from sexual harassment and for a moderate depressive episode. She had been diagnosed with idiopathic generalized absence epilepsy in childhood, but had experienced no seizures under lamotrigine medication since 1999. After the second EMDR session, clinical seizures in the form of absences occurred, and were validated by electroencephalography. The seizures ceased after medication with benzodiazepines and an increase in the lamotrigine level. She underwent four more sessions of EMDR treatment successfully without further seizures. Possible triggers are discussed, especially as to whether EMDR treatment played a role in reactivating epilepsy. Further research and publications on the application of EMDR in epilepsy patients are needed.
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Affiliation(s)
- Gudrun Schneider
- Department of Psychosomatics and Psychotherapy, University of Münster, Domagkstrasse 22, D-48149 Münster, Germany.
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Völker W, Besselmann M, Dittrich R, Nabavi D, Konrad C, Dziewas R, Evers S, Grewe S, Krämer SC, Bachmann R, Stögbauer F, Ringelstein EB, Kuhlenbäumer G. Generalized arteriopathy in patients with cervical artery dissection. Neurology 2005; 64:1508-13. [PMID: 15883309 DOI: 10.1212/01.wnl.0000159739.24607.98] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To make an ultrastructural comparison of superficial temporal artery (STA) biopsy specimens from patients with spontaneous cervical artery dissection (sCAD) and controls. METHODS The authors used light microscopic examination of semithin sections and electron microscopic examination of ultrathin sections of STA biopsy specimens from patients with sCAD and controls. RESULTS STA biopsy specimens from patients with sCAD taken around the time of the dissection showed a zone of connective tissue weakening with fissuring at the junction between the tunica media (TM) and the tunica adventitia (TA) in seven of nine specimens and erythrocyte infiltration in eight of nine specimens but in none of the control specimens. Light microscopy demonstrated transparent circular spots that, on electron microscopy, turned out to represent erythrocytes and other cellular components at different stages of degradation. Occasionally, scattered immune cells were found in specimens from patients with sCAD. In addition, smooth muscle cells of the synthetic phenotype, some of them showing extensive vacuolation were more common in the TM of STA biopsy specimens from patients with sCAD than in control specimens. CONCLUSIONS Signs of tissue weakening along the TM/TA junction in STA biopsy specimens of patients with sCAD but not in controls suggest the presence of a generalized arteriopathy leading to impairment of the stability of the arterial wall in patients with sCAD. Limiting factors of the study are that some control biopsies were obtained from autopsies and that the anticoagulation status of patients and controls were not completely comparable.
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Affiliation(s)
- W Völker
- Institute of Atherosclerosis Research, University of Münster, Münster, Germany
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Evers S, Nabavi D, Rahmann A, Heese C, Reichelt D, Husstedt IW. Ischaemic cerebrovascular events in HIV infection: a cohort study. Cerebrovasc Dis 2003; 15:199-205. [PMID: 12646780 DOI: 10.1159/000068828] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2002] [Accepted: 06/03/2002] [Indexed: 11/19/2022] Open
Abstract
Several case reports and series described ischaemic cerebrovascular events in HIV infection. However, the exact prevalence and the clinical features of these events are unknown. We performed a cohort study on 772 consecutive HIV infected patients and evaluated the rate of transient ischaemic attacks (TIA) and of completed stroke. A total prevalence of 1.9% for TIA (0.8%) and stroke (1.2%) was calculated resulting in an annual incidence rate of 216 per 100000. The prevalence was highest in the later stages of the infection. Stroke patients had a poorer immunological state than the TIA and the cohort patients. Probable (n = 3) and possible (n = 2) vasculitis and cardiogenic embolism (n = 2) could be detected as aetiology, the remaining patients had a cryptogenic event. Our data suggest that ischaemic cerebrovascular events are more common in HIV infected patients than in the general population and that a part of these events might be caused by HIV associated vasculitis or vasculopathy.
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Affiliation(s)
- Stefan Evers
- Department of Neurology, University of Münster, Germany.
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Droste DW, Jekentaite R, Stypmann J, Grude M, Hansberg T, Ritter M, Nabavi D, Nam EM, Dittrich R, Wichter T, Ringelstein EB. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of Echovist-200 and Echovist-300, timing of the Valsalva maneuver, and general recommendations for the performance of the test. Cerebrovasc Dis 2002; 13:235-41. [PMID: 12011547 DOI: 10.1159/000057849] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Cardiac right-to-left shunts (RLS) can be identified by transesophageal echocardiography (TEE) as well as by transcranial Doppler ultrasound (TCD) using contrast agents, such as Echovist-200 or Echovist-300 in conjunction with a Valsalva maneuver (VM) as provocation procedure. Both Echovist preparations are in use. Currently, the appropriate timing of the VM is still under debate. METHODS Sixty-four patients were investigated by both TEE and bilateral TCD of the middle cerebral arteries. The following protocol was applied in a randomized way: (1) no VM, (2) VM for 5 s starting with the beginning of Echovist-300 injection, (3) VM for 5 s starting 5 s after the beginning of Echovist-300 injection, (4) VM for 5 s starting 10 s after the beginning of Echovist-300 injection, and (5) VM for 5 s starting 5 s after the beginning of Echovist-200 injection. RESULTS In 27 patients, an RLS was demonstrated by both TEE and contrast TCD (shunt-positive). Twenty-two patients were negative in both investigations, no patient was positive on TEE but negative on TCD, 15 patients were only positive on at least one TCD investigation but negative on TEE. Tests 3 and 5 were the most appropriate ones; test 3 was slightly superior to test 5. CONCLUSIONS TCD using Echovist-300 or Echovist-200 is a sensitive method to identify TEE-proven cardiac RLS. To achieve the best diagnostic accuracy, the VM should be performed for a duration of 5 s starting at 5 s following the beginning of contrast injection.
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Affiliation(s)
- Dirk W Droste
- Department of Neurology, University of Münster, Münster, Germany.
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Abstract
OBJECTIVE The purpose of this study was to determine whether participation in sports by persons with spinal cord injuries (SCIs) affected level of community integration as defined by the World Health Organization and as measured by the Craig Handicap Assessment and Reporting Technique (CHART). METHOD Forty-eight participants were recruited from a camp for persons with physical disabilities as well as from SCI support groups. Participants were divided into groups of athletes (n = 30) and nonathletes (n = 18) on the basis of their self-reported level of sports participation. RESULTS Athletes scored significantly higher on four of five subsections of the CHART (physical independence, mobility, occupation, social integration), indicating greater levels of community integration than nonathletes. CONCLUSION These findings extend the literature outlining the physical and psychological benefits of sports. Occupational therapists have a unique opportunity to use the occupation of sports to integrate the roots of the profession with the cultural demands of society.
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Affiliation(s)
- C S Hanson
- Department of Occupational Therapy, University of Florida, PO Box 100164, Gainesville, Florida 32610, USA.
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Abstract
Stroke is the third most important cause of mortality, but the leading cause of severe handicap, dependency, and loss of social competence. Because of the high recurrence rate, active secondary prevention is mandatory once a stroke has occurred. Secondary prevention of stroke implies the primary prevention of cardiovascular disorders as well. Among the modifiable risk factors hypertension is worst and should be normalized according to recent WHO criteria, also in the elderly. Smoking is another major risk factor and hard to delete. Diabetes mellitus and hyperlipidaemia are also important risk factors and should be treated consequently by diet and medication. Moderate alcohol intake, normalization of body weight and regular physical activity also contribute considerably to prevention of stroke. Whether hyperhomocysteinaemia should be normalized has not yet been clarified. Cardiovascular disorders are an important source of ischemic strokes, particularly atrial fibrillation. Low dose anticoagulation can dramatically reduce stroke risk. Carotid endarterectomy in symptomatic stenoses is the most expensive means of stroke prevention. In less severe stenoses, or ICA occlusions, antiplatelet agents are the treatment of choice. Composite drugs with ASS and other antiplatelet agents seem to be superior to either compound alone. Dissections of the cervical arteries should not be operated on but may be treated by anticoagulation or antiplatelet agents in the acute and subacute phase. The potency of a consequent and comprehensive stroke prevention in preventing disability and death is much greater than any sophisticated acute stroke treatment.
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Affiliation(s)
- E B Ringelstein
- Klinik und Poliklinik für Neurologie, Westfälische Wilhelms Univerität Münster, Münster, Germany
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Schmid C, Wilhelm M, Rothenburger M, Nabavi D, Deng MC, Hammel D, Scheld HH. Effect of high dose platelet inhibitor treatment on thromboembolism in Novacor patients. Eur J Cardiothorac Surg 2000; 17:331-5. [PMID: 10758396 DOI: 10.1016/s1010-7940(00)00334-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Thromboembolism and bleeding are among the most hazardous complications following implantation of long-term left ventricular support systems. This report focuses on the effect of high dose platelet inhibitor treatment in patients with the Novacor system to prevent thromboembolic events. METHODS Thirty-eight (out of 58) Novacor patients (43+/-11 years old) were studied in a non-randomized manner. Postimplantation: 20 patients were treated with heparin only (control group), whereas in the other 18 patients aspirin (3x330 mg/day) and dipyridamol (3x75 mg/day) were added to the treatment protocol (aspirin group). RESULTS Age, body size, underlying heart disease and support interval were comparable among both groups, however, patients in the aspirin group were much sicker with regard to urgency status, postoperative right heart failure and hematologic disorders. Cerebral thromboembolic complications were lower in the aspirin group (33% of patients, 0.4+/-0.7 events) as compared to the control group (55% (P=0.18), 1.4+/-2.3 events (P=0. 048)). Non-cerebral thromboembolism of surgical relevance was rare. The incidence of bleeding complications was mildly increased in the aspirin group. CONCLUSION The addition of high dose platelet inhibitors seems to lower the incidence of thromboembolism in Novacor patients.
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Affiliation(s)
- C Schmid
- Department of Cardiothoracic Surgery, Westfälische Wilhelms-University Münster, Germany.
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Schmid C, Weyand M, Hammel D, Deng MC, Nabavi D, Scheld HH. Effect of platelet inhibitors on thromboembolism after implantation of a Novacor N100--preliminary results. Thorac Cardiovasc Surg 1998; 46:260-2. [PMID: 9885115 DOI: 10.1055/s-2007-1010235] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Left-ventricular assist device implantation (LVAD) is still associated with thromboembolism as the optimal anticoagulation is still unclear. We report on the effects of adding platelet inhibitors to our anticoagulation regimen in our Novacor LVAD program. METHODS Oral platelet aggregation inhibitors (aspirin 330 mg + dipyridamole 75 mg, three times per day) were added to the heparin/phenprocoumon treatment in 9 patients starting on postoperative day 3 to 7 (group A). Of the previous 41 patients, the last 20 patients served as a control group (group B), to reduce any learning curve effect. RESULTS The mean interval of mechanical support between the two groups was comparable (group A vs B: 148 +/- 127 vs 104 +/- 61 days, n.s.). Accordingly, the cumulative support was much lower in group A (1051 days) as compared to group B (2091 days). In group B, 10 patients (50%) developed clinically evident thromboembolism. The number of events ranged from 1 to 10 (mean 1.4 +/- 2.3), with a total of 32. With addition of platelet inhibitors, the incidence of cerebral embolism dramatically dropped, as only one patient presented with transient ischemic attacks in group A (p < 0.05). Thoracic bleeding as defined by excessive drainage losses requiring redo thoracotomy did not increase (group A vs B: 22% vs 20%, n.s.). CONCLUSION Addition of platelet inhibitors to heparin/phenprocoumon effectively prevents thromboembolism. However, platelet inhibitors should be postponed until sufficient hemostasis is achieved, since too early administration is associated with an increased risk of bleeding.
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Affiliation(s)
- C Schmid
- Department of Thoracic and Cardiovascular Surgery, Westfalian Wilhelms University, Münster, Germany
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Georgiadis D, König M, Zunker P, Nabavi D, Stögbauer F, Ringelstein EB. Microembolic signals inpatients referred for echocardiography. Stroke 1995; 26:525; author reply 526-7. [PMID: 7886738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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