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Connolly SJ, Milling TJ, Eikelboom JW, Gibson CM, Curnutte JT, Gold A, Bronson MD, Lu G, Conley PB, Verhamme P, Schmidt J, Middeldorp S, Cohen AT, Beyer-Westendorf J, Albaladejo P, Lopez-Sendon J, Goodman S, Leeds J, Wiens BL, Siegal DM, Zotova E, Meeks B, Nakamya J, Lim WT, Crowther M. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med 2016; 375:1131-41. [PMID: 27573206 PMCID: PMC5568772 DOI: 10.1056/nejmoa1607887] [Citation(s) in RCA: 540] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Andexanet alfa (andexanet) is a recombinant modified human factor Xa decoy protein that has been shown to reverse the inhibition of factor Xa in healthy volunteers. METHODS In this multicenter, prospective, open-label, single-group study, we evaluated 67 patients who had acute major bleeding within 18 hours after the administration of a factor Xa inhibitor. The patients all received a bolus of andexanet followed by a 2-hour infusion of the drug. Patients were evaluated for changes in measures of anti-factor Xa activity and were assessed for clinical hemostatic efficacy during a 12-hour period. All the patients were subsequently followed for 30 days. The efficacy population of 47 patients had a baseline value for anti-factor Xa activity of at least 75 ng per milliliter (or ≥0.5 IU per milliliter for those receiving enoxaparin) and had confirmed bleeding severity at adjudication. RESULTS The mean age of the patients was 77 years; most of the patients had substantial cardiovascular disease. Bleeding was predominantly gastrointestinal or intracranial. The mean (±SD) time from emergency department presentation to the administration of the andexanet bolus was 4.8±1.8 hours. After the bolus administration, the median anti-factor Xa activity decreased by 89% (95% confidence interval [CI], 58 to 94) from baseline among patients receiving rivaroxaban and by 93% (95% CI, 87 to 94) among patients receiving apixaban. These levels remained similar during the 2-hour infusion. Four hours after the end of the infusion, there was a relative decrease from baseline of 39% in the measure of anti-factor Xa activity among patients receiving rivaroxaban and of 30% among those receiving apixaban. Twelve hours after the andexanet infusion, clinical hemostasis was adjudicated as excellent or good in 37 of 47 patients in the efficacy analysis (79%; 95% CI, 64 to 89). Thrombotic events occurred in 12 of 67 patients (18%) during the 30-day follow-up. CONCLUSIONS On the basis of a descriptive preliminary analysis, an initial bolus and subsequent 2-hour infusion of andexanet substantially reduced anti-factor Xa activity in patients with acute major bleeding associated with factor Xa inhibitors, with effective hemostasis occurring in 79%. (Funded by Portola Pharmaceuticals; ANNEXA-4 ClinicalTrials.gov number, NCT02329327 .).
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Affiliation(s)
- Stuart J Connolly
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Truman J Milling
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - John W Eikelboom
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - C Michael Gibson
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - John T Curnutte
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Alex Gold
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Michele D Bronson
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Genmin Lu
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Pamela B Conley
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Peter Verhamme
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Jeannot Schmidt
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Saskia Middeldorp
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Alexander T Cohen
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Jan Beyer-Westendorf
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Pierre Albaladejo
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Jose Lopez-Sendon
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Shelly Goodman
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Janet Leeds
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Brian L Wiens
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Deborah M Siegal
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Elena Zotova
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Brandi Meeks
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Juliet Nakamya
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - W Ting Lim
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
| | - Mark Crowther
- From the Population Health Research Institute, McMaster University, Hamilton ON, Canada (S.J.C., J.W.E., D.M.S., E.Z., B.M., J.N., W.T.L., M.C.); Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.); Harvard Medical School, Boston (C.M.G.); Portola Pharmaceuticals, San Francisco (J.T.C., A.G., M.D.B., G.L., P.B.C., S.G., J.L., B.L.W.); University of Leuven, Leuven, Belgium (P.V.); Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand (J.S.), and Grenoble-Alpes University Hospital, Grenoble (P.A.) - both in France; Academic Medical Center, Amsterdam (S.M.); Guy's and St. Thomas' Hospitals, King's College London, London (A.T.C.); University Hospital Carl Gustav Carus Dresden, Dresden, Germany (J.B.-W.); and Hospital Universitario La Paz, Madrid (J.L.-S.)
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