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Schöchl H, Grottke O, Schmitt FCF. Direct oral anticoagulants in trauma patients. Curr Opin Anaesthesiol 2024; 37:93-100. [PMID: 38390987 DOI: 10.1097/aco.0000000000001356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOACs) are increasingly prescribed for prevention of thromboembolic events. Thus, trauma care providers are facing a steadily raising number of injured patients on DOACs. RECENT FINDINGS Despite a predictable pharmacokinetic profile, the resulting plasma levels of trauma patients upon admission and bleeding risks remain uncertain. Therefore, recent guidelines recommend the measurement of DOAC plasma concentrations in injured patients. Alternatively, DOAC specific visco-elastic tests assays can be applied to identify DOAC patients at bleeding risk.Bleeding complications in trauma patients on DOACs are generally higher compared to nonanticoagulated subjects, but comparable to vitamin K antagonists (VKAs). In particular, a traumatic brain injury does not carry an increased risk of intracranial bleeding due to a DOAK intake compared to VKAs. Current studies demonstrated that up to 14% of patients with a hip fracture are on DOACs prior to surgery. However, the majority can be operated safely within a 24h time window without an increased bleeding rate.Specific antagonists facilitate rapid reversal of patients on DOACs. Idarucizumab for dabigatran, and andexanet alfa for apixaban and rivaroxaban have been approved for life threatening bleeding. Alternatively, prothrombin complex concentrate can be used. Dialysis is a potential treatment option for dabigatran and haemoabsorption with special filters can be applied in patients on FXa-inhibitors. SUMMARY Current guidelines recommend the measurement of DOAC plasma levels in trauma patients. Compared to VKAs, DOACs do not carry a higher bleeding risk. DOAC specific antagonists facilitate the individual bleeding management.
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Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The research centre in cooperation with AUVA, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Doeppner TR, Olbricht L, Maxhuni T, Alhaj Omar O, Sachs UJ, Juenemann MB, Huttner HB, Gerner ST. Urine-based point-of-care testing for factor-Xa-inhibitors in acute ischemic stroke patients: a feasibility study. Front Neurol 2023; 14:1330421. [PMID: 38162451 PMCID: PMC10756232 DOI: 10.3389/fneur.2023.1330421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) have become widely used in clinical practice for preventing thromboembolic events. Point-of-care testing methods, particularly those based on urine samples, offer a promising approach for rapid and accurate assessment of DOAC presence. This pilot study aims to evaluate the utility of a urine-based DOAC dipstick test as a point-of-care tool for identifying DOAB presence in acute ischemic stroke (AIS) or transient ischemic attack (TIA) patients. Patients and methods This prospective pilot study included patients with AIS/TIA eligible for DOAC-measurement. After exclusion of 3 patients, 23 patients with DOAC-intake (DOAC group; factor-Xa-inhibitors; n = 23) and 21 patients without DOAC-intake (control-group) remained for analyses. The urine-based DOAC dipstick test and parallel blood-based specific DOAC-level assessment were performed in all patients. Time-intervals of sampling urine/blood sampling and result of DOAC-test were recorded to analyze a potential time benefit based on dipstick evaluation. Results The urine-based DOAC dipstick test demonstrated high sensitivity (100%) and specificity (100%), correctly identifying all patients with anticoagulatory activity due to DOAC intake (i.e., anti-Xalevel ≥30 ng/mL). Moreover, the visual readout of the test provided semiquantitative information on drug-specific anti-Xa levels, showing a sensitivity of 83% and specificity of 93% to detect anti-Xa levels ≥120 ng/mL. The dipstick test exhibited a median time-benefit of 2:25 h compared to standard blood-based DOAC-level testing. Discussion The results of this pilot study underline the efficacy of urine-based point-of-care testing as a rapid and reliable method for assessing DOAC presence in patients with acute ischemic stroke. Conclusion The value of this tool for clinical decision-making in stroke management needs to be established in future trials.Clinical Trial Registration: Clinicaltrails.org identifier [NCT06037200].
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Affiliation(s)
- Thorsten R. Doeppner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Linus Olbricht
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Toska Maxhuni
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Omar Alhaj Omar
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Ulrich J. Sachs
- Division of Haemostaseology, University Hospital Giessen, Giessen, Germany
| | | | - Hagen B. Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
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Ruoff C, Schöchl H, Fritsch G, Voelckel W, Zipperle J, Gratz J, Schmitt F, Oberladstätter D. DOAC plasma concentration upon hospital admission in a cohort of trauma patients. An observational real-life study. Eur J Trauma Emerg Surg 2023; 49:2543-2551. [PMID: 37500912 DOI: 10.1007/s00068-023-02334-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Due to a better safety profile, direct oral anticoagulants (DOACs) are increasingly prescribed for prevention of thromboembolic events. However, little is known about DOAC plasma concentrations in trauma patients upon hospital admission. Thus, we investigated the frequency and extent of DOAC possible over- and underdosing in trauma patients upon hospital admission. METHODS In this single-center retrospective study, DOAC plasma concentrations of adult trauma patients were analyzed with specific calibrated anti-IIa (dabigatran) and anti-Xa (apixaban, edoxaban and rivaroxaban) tests within 4 h after hospital admission. RESULTS A total of 210 trauma patients, admitted between 2019 and 2022, were included in the analyses. Low DOAC levels < 30 ng/mL were detected in 13.3% of the patients. In 7.1% of the patients, DOAC plasma levels ranged between 300-399 ng/mL and further 7.1% exhibited plasma concentrations > 400 ng/mL. The highest incidence of high to very high DOAC plasma concentration was observed for patients on rivaroxaban and dabigatran. A moderate correlation was observed between dabigatran plasma concentration and estimated glomerular filtration rate (rho = - 0.5338, p = 0.0003). For rivaroxaban no clear association between plasma concentration and liver or renal function could be detected. Patients on statins had significantly higher DOAC concentration in comparison with those not taking statins (153 (76-274) vs 108 (51-217) ng/mL, p = 0.046). CONCLUSION The current study revealed that patients on dabigatran and rivaroxaban were prone to higher DOAC plasma levels upon hospital admission in comparison with apixaban and edoxaban. DOAC plasma level measurement in trauma patients might be warranted due to unpredictively low or high plasma concentrations. However, the clinical impact of altered plasma levels on both, bleeding and thromboembolic events, remains to be determined by future studies.
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Affiliation(s)
- Carolin Ruoff
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020, Salzburg, Austria
- Paracelsus Medical University, Salzburg, Austria
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020, Salzburg, Austria.
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation With AUVA, Vienna, Austria.
| | - Gerhard Fritsch
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020, Salzburg, Austria
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation With AUVA, Vienna, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020, Salzburg, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation With AUVA, Vienna, Austria
| | - Johannes Gratz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Felix Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020, Salzburg, Austria
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation With AUVA, Vienna, Austria
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Baturina O, Chashkina M, Andreev D, Mirzaev K, Bykova A, Suvorov A, Yeryshova D, Suchkova S, Sychev D, Syrkin A. Pharmacokinetic and Pharmacogenetic Predictors of Major Bleeding Events in Patients with an Acute Coronary Syndrome and Atrial Fibrillation Receiving Combined Antithrombotic Therapy. J Pers Med 2023; 13:1371. [PMID: 37763139 PMCID: PMC10532904 DOI: 10.3390/jpm13091371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Objective: This study's objective was to evaluate the effects of pharmacokinetic and pharmacogenetic factors on major bleeding in patients with ACS and non-valvular AF receiving combined antithrombotic therapy consisting of rivaroxaban, clopidogrel, and aspirin as part of dual or triple therapy. Methods: A prospective observational study was conducted in two PCI centers in Moscow, the Russian Federation, from 2017 to 2018. One hundred patients with ACS and AF were enrolled. Prospective follow-ups continued for 12 months. Results: A total of 36 patients experienced bleeding events, with 10 experiencing major bleeding based on the BARC scale and 17 experiencing major bleeding based on the ISTH scale. The following predictors associated with an increased number of major bleeding events were identified: for the ISTH scale, a Css min. of rivaroxaban of >137 pg/mL (5.94 OR, (95% CI, 3.13-12.99; p < 0.004)) and carriage of the T allelic variant polymorphism ABCB1 rs4148738 (8.97 OR (95% CI, 1.48-14.49; p < 0.017)), as well as for the BARC scale (5.76 OR (95% CI, 2.36-9.87; p < 0.018)). Conclusions: Measuring residual steady-state rivaroxaban concentrations and determining the carriage of the T allelic variant polymorphism ABCB1 rs4148738 may be applicable to high-risk patients for subsequent antithrombotic therapy modification.
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Affiliation(s)
- Olga Baturina
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Maria Chashkina
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Denis Andreev
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Karin Mirzaev
- Clinical Pharmacology and Therapy Department B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow 125993, Russia; (K.M.); (D.S.)
| | - Alexandra Bykova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Alexandr Suvorov
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia;
| | - Daria Yeryshova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Svetlana Suchkova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Dmitry Sychev
- Clinical Pharmacology and Therapy Department B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow 125993, Russia; (K.M.); (D.S.)
| | - Abram Syrkin
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
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Galea R, Seiffge D, Räber L. Atrial Fibrillation and Ischemic Stroke despite Oral Anticoagulation. J Clin Med 2023; 12:5784. [PMID: 37762726 PMCID: PMC10532406 DOI: 10.3390/jcm12185784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with atrial fibrillation (AF) experiencing ischemic stroke despite oral anticoagulation (OAC), i.e., breakthrough strokes, are not uncommon, and represent an important clinical subgroup in view of the consistently high risk of stroke recurrence and mortality. The understanding of the heterogenous potential mechanism underlying OAC failure is essential in order to implement specific therapeutic measures aimed at reducing the risk of recurrent ischemic stroke. However, due to the incomplete comprehension of this phenomenon and the limited available data, secondary stroke prevention in such high-risk patients represents a clinical dilemma. There are several available strategies to prevent ischemic stroke recurrence in AF patients with breakthrough stroke in the absence of competing causes unrelated to AF, and these include continuation or change in the type of OAC, addition of antiplatelet therapy, left atrial appendage closure, or any combination of the above options. However, due to the limited available data, the latest guidelines do not provide any specific recommendations about which of the above strategies may be preferred. This review describes the incidence, the clinical impact and the potential mechanisms underlying OAC failure in AF patients. Furthermore, the evidence supporting each of the above therapeutic options for secondary stroke prevention and the potential future directions will be discussed.
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Affiliation(s)
- Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
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Role of DOAC plasma concentration on perioperative blood loss and transfusion requirements in patients with hip fractures. Eur J Trauma Emerg Surg 2023; 49:165-172. [PMID: 35841427 DOI: 10.1007/s00068-022-02041-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is an ever-increasing number of hip fracture (HF) patients on direct oral anticoagulants (DOAC). The impact of DOAC plasma level prior to HF surgery on perioperative blood loss and transfusion requirements has not been investigated so far. MATERIALS AND METHODS In this retrospective study of HF patients on DOACs admitted to the AUVA Trauma Center Salzburg between February 2015 and December 2021. DOAC plasma levels were analysed prior to surgery. Patients were categorized into four DOAC groups: Group A < 30 ng/mL, Group B 30-49 ng/mL, Group C 50-79 ng/mL, and Group D ≥ 80 ng/mL. Haemoglobin concentration was measured upon admission, prior to surgery, after ICU/IMC admission, and on day 1 and 2 post-surgery. Difference in the blood loss via drains, transfusion requirements and time to surgery were compared. RESULTS A total of 155 subjects fulfilled the predefined inclusion criteria. The median age of the predominantly female patients was 86 (80-90) years. Haemoglobin concentration in Group D was lower upon admissions but did not reach statistical significance. The decrease in haemoglobin concentration over the entire observation time was comparable between groups. Blood transfusion requirements were significantly higher in Group D compared to Group A and B (p = 0.0043). Time to surgery, intra- and postoperative blood loss via drains were not different among groups. CONCLUSION No strong association between the DOAC plasma levels and perioperative blood loss was detected. Higher transfusion rates in patients with DOAC levels ≥ 80 ng/mL were primarily related to lower admission haemoglobin levels. DOAC concentration measurement is feasible and expedites time to surgery.
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Okada T, Yoshimoto T, Wada S, Yoshimura S, Chiba T, Egashira S, Kimura S, Shiozawa M, Inoue M, Ihara M, Toyoda K, Takashima H, Koga M. Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants. J Am Heart Assoc 2022; 11:e025809. [PMID: 36129032 PMCID: PMC9673692 DOI: 10.1161/jaha.122.025809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset. Methods and Results Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P=0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P=0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months. Conclusions Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665.
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Affiliation(s)
- Takashi Okada
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Chen JH, Hong CT, Chung CC, Kuan YC, Chan L. Safety and efficacy of endovascular thrombectomy in acute ischemic stroke treated with anticoagulants: a systematic review and meta-analysis. Thromb J 2022; 20:35. [PMID: 35729578 PMCID: PMC9210791 DOI: 10.1186/s12959-022-00394-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Endovascular thrombectomy (EVT) is an effective therapy in acute ischemic stroke (AIS) with large vessel occlusion, especially for those who are unsuitable for intravenous thrombolysis. However, the safety and efficacy of EVT in AIS patients who receiving oral anticoagulants (OACs) is unclear, especially for the risk of symptomatic intracranial hemorrhage (sICH). Methods Database of PubMed, Embase, and Cochrane Library were searched from Jan 1, 2000, through the final search date of Jun 2, 2021. Eligible studies for enrollment required outcomes reported for events of sICH, mortality, functional status, and successful reperfusion. Meta-analysis was conducted to compare the outcomes difference after EVT between AIS patients with or without OACs use. The primary safety outcome was sICH after EVT, and the primary efficacy outcome was functional status at 3 months. Results One thousand nine hundred forty studies were screened for eligibility and 15 of them were included in the meta-analysis. Compared the OACs group to control arm, vitamin K antagonists (VKAs) was associated with higher risk of sICH (OR 1.49, 95% CI 1.10–2.02) and mortality (OR 1.67, 95% CI 1.35–2.06). Poor functional outcomes were noted both in the VKAs and direct oral anticoagulants (DOACs) groups (OR 0.62, 95% CI 0.54–0.71 and OR 0.61, 95% CI 0.53–0.71, respectively). No differences in successful reperfusion were observed. Conclusions Comparing with DOACs, VKAs use was associated with a higher risk of sICH and mortality after EVT. Patients who did not receive OACs exhibited more favorable outcomes. The successful reperfusion did not differ between groups. However, results for mortality and functional outcomes have to be interpreted with caution since they are based on non-randomized data and unadjusted proportions. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00394-y.
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Affiliation(s)
- Jia-Hung Chen
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Chih Chung
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Lung Chan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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10
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Sin CF, Wong KP, Wong HM, Siu CW, Yap DYH. Plasma Rivaroxaban Level in Patients With Early Stages of Chronic Kidney Disease-Relationships With Renal Function and Clinical Events. Front Pharmacol 2022; 13:888660. [PMID: 35662694 PMCID: PMC9157352 DOI: 10.3389/fphar.2022.888660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Drug accumulation of rivaroxaban is a concern in patients with chronic kidney disease (CKD). Data regarding the plasma rivaroxaban levels in early CKD patients and its relationship with clinical events is lacking. Methods Early CKD patients (Stage 1-3) with atrial fibrillation who received rivaroxaban (15 or 20 mg daily) were recruited. Plasma rivaroxaban levels were measured at 2 hours (peak) and 24 hours (trough) after drug administration, and correlated with eGFR and clinically significant events during the follow-up period (1 January 2018 to 31 October 2021). Results Ninety-two patients were included (CKD stage 1 n=10, stage 2 n=53, stage 3 n=29). Plasma trough levels in patients with stage 3 CKD were significantly higher than those with stage 2 and 1 CKD (66.0±34.9 ng/ml vs. 35.7 ± 24.7 ng/ml vs. 34.7 ± 26.2 ng/ml, respectively, p=0.005), and showed inverse relationship with eGFR (r=0.391, p=0.001) in patients receiving 20 mg daily. The plasma trough rivaroxaban level correlated with PT and APTT (r = 0.650 and 0.44, respectively, p<0.001 for both). Plasma trough rivaroxaban level in those with bleeding were higher than those who did not (59.9 ± 35.6 ng/ml vs. 41.1 ± 29.2 ng/ml, p=0.011), and multivariate analysis suggested that plasma trough rivaroxaban level was associated with the rate of bleeding complications (OR: 1.020, 95% CI 1.002-1.038, p=0.028). Conclusion Plasma trough rivaroxaban levels correlated with renal function in early CKD patients, and its measurement may help dosage optimization in patients with renal impairment. Moreover, our data suggests that there may be an association between plasma trough rivaroxaban level and the rate of bleeding complication.
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Affiliation(s)
- Chun-Fung Sin
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ka-Ping Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hoi-Man Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chung-Wah Siu
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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11
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Seiffge DJ. Intravenous Thrombolytic Therapy for Treatment of Acute Ischemic Stroke in Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants. JAMA 2022; 327:725-726. [PMID: 35143602 DOI: 10.1001/jama.2022.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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12
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Rizos T, Meid AD, Huppertz A, Dumschat C, Purrucker J, Foerster KI, Burhenne J, Czock D, Jenetzky E, Ringleb PA, Haefeli WE. Low Exposure to Direct Oral Anticoagulants Is Associated with Ischemic Stroke and Its Severity. J Stroke 2022; 24:88-97. [PMID: 35135063 PMCID: PMC8829480 DOI: 10.5853/jos.2020.04952] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 09/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background and purpose In acute stroke patients, plasma concentrations of direct oral anticoagulants (DOAC) at hospital admission only poorly mirror DOAC exposure or the coagulation status at the time of the event. Here, we evaluated whether DOAC exposure and DOAC plasma concentration at the time of transient ischemic attacks (TIA) and ischemic strokes correlate with their likelihood of occurrence.
Methods Prospectively, consecutive DOAC patients with acute ischemic stroke or TIA were included. Admission DOAC plasma concentrations were measured by ultraperformance liquid chromatography– tandem mass spectrometry. Individual DOAC exposure (area under the curve) and DOAC concentrations at event onset were derived from population pharmacokinetic analyses.
Results DOAC exposure was successfully modeled in 211 patients (ischemic stroke 74.4%, TIA 25.6%). Compared to published values, 63.0% had relatively lower DOAC exposure and they more often received lower DOAC doses than recommended (odds ratio [OR], 2.125; 95% confidence interval [CI], 1.039 to 4.560; P=0.044). These patients more likely suffered ischemic strokes than TIA (OR, 2.411; 95% CI, 1.254 to 4.638; P=0.008) and their strokes were more severe (slope, 3.161; 95% CI, 0.741 to 5.58; P=0.011). Low relative DOAC concentrations at event onset were likewise associated with ischemic strokes (OR, 4.123; 95% CI, 1.834 to 9.268; P=0.001), but not to stroke severity (P=0.272). DOAC exposure had a higher explanatory value for stroke severity than concentrations at event.
Conclusions Low DOAC exposure is strongly associated to ischemic stroke and its severity. By monitoring DOAC plasma concentrations, patients prone to ischemic stroke might be identified.
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Affiliation(s)
- Timolaos Rizos
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
- Correspondence: Timolaos Rizos Department of Neurology, University Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany Tel: +49-6221-56-7504 Fax: +49-6221-56-5654 E-mail:
| | - Andreas D. Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Andrea Huppertz
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Chris Dumschat
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Ekkehart Jenetzky
- Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany
- Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | - Peter A. Ringleb
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
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13
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Artang R, Dias JD, Walsh M, Bliden K, Nielsen JD, Anderson M, Thurston BC, Tantry US, Hartmann J, Gurbel PA. Measurement of Anticoagulation in Patients on Dabigatran, Rivaroxaban, and Apixaban Therapy by Novel Automated Thrombelastography. TH OPEN 2022; 5:e570-e576. [PMID: 34984316 PMCID: PMC8718262 DOI: 10.1055/a-1692-1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 11/04/2021] [Indexed: 10/25/2022] Open
Abstract
Background Direct-acting oral anticoagulants (DOACs) do not require monitoring. Measurement of DOAC effect would be useful in the event of bleeding, trauma, and thromboembolism while on anticoagulation. We evaluated the effectiveness of the investigational DOAC assays on the TEG®6s Hemostasis Analyzer to assess the anticoagulant effect of DOACs in patients treated for atrial fibrillation or deep vein thrombosis (DVT). Methods Patients on treatment for a minimum of 7 days with standard doses of dabigatran, rivaroxaban, and apixaban were included. DOAC plasma concentrations and TEG®6s Reaction (R)-time were measured and correlated. The sensitivity, specificity, and negative predictive value (NPV) of R-time to detect DOAC concentrations of ≥30, ≥50, and ≥100 ng/mL were calculated. Results A total of 189 patients were included, ( n = 50) on apixaban, ( n = 62) on rivaroxaban, ( n = 53) on dabigatran, and ( n = 24) on no DOAC were studied. Using the direct thrombin inhibitor (DTI) channel, R-time demonstrated strong linear correlation with dabigatran levels (r = 0.93, p < 0.0001). Using the antifactor Xa (AFXa) channel, R-time demonstrated strong nonlinear correlation with rivaroxaban and apixaban levels ( r s = 0.92 and 0.84, respectively, p < 0.0001 for both). R-time revealed strong sensitivity and NPV in detecting low DOAC levels for the predefined concentrations. Conclusion R-time measured by TEG®6s DOAC-specific cartridge has a strong correlation with concentrations of the most commonly used DOACs with high sensitivity and NPV for detecting lower drug levels that are considered clinically relevant for patients in need of antidote, or prior to urgent surgery. Further studies to determine the relation of R-time to clinical outcomes are warranted.
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Affiliation(s)
- Ramin Artang
- Essentia Health St. Mary's Heart and Vascular Center, Duluth, Minnesota, United States.,Bispebjerg University of Copenhagen Hospital, Department of Cardiology, Copenhagen, Denmark
| | - Joao D Dias
- Haemonetics Corp., Braintree, Massachusetts, United States
| | - Mark Walsh
- Memorial Hospital of South Bend, Department of Energy Medicine, Sound Bend, Indiana, United States
| | - Kevin Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Jorn D Nielsen
- Bispebjerg University of Copenhagen Hospital, Department of Cardiology, Copenhagen, Denmark
| | - Maren Anderson
- University of Minnesota School of Medicine, Duluth, Minnesota, United States
| | - Brian C Thurston
- Spartanburg Regional Medical Center, Division of Surgery, Spartanburg, South Carolina, United States
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Jan Hartmann
- Haemonetics Corp., Braintree, Massachusetts, United States
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
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14
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Perifanis V, Neokleous N, Tsakiris DA. Update on laboratory testing and hemostasis assessment in patients receiving direct oral anticoagulants (DOACs). THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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15
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Siller T, Chandratheva A, Bücke P, Werring DJ, Seiffge D. Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option? Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.
Recent Findings
Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.
Summary
IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.
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16
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Stretz C, Wu TY, Wilson D, Seiffge DJ, Smith EE, Gurol ME, Yaghi S. Ischaemic stroke in anticoagulated patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2021; 92:1164-1172. [PMID: 34446528 DOI: 10.1136/jnnp-2020-323963] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023]
Abstract
Anticoagulation substantially reduces the risk of stroke in patients with atrial fibrillation (AF). However, recent studies have shown that up to 22%-36% of patients on anticoagulation will suffer an ischaemic stroke (IS). In this narrative review, we provide an overview of risk factors, mechanisms, management of acute IS and strategies for secondary prevention for patients with AF with stroke despite oral anticoagulation. For this paper, we reviewed available literature from important studies (randomised clinical trials, meta-analyses, reviews and case series) on patients with IS despite anticoagulation. We focused on recent studies that examined safety and efficacy of acute stroke treatments and evaluation and management strategies for secondary prevention. The literature review suggests that patients with AF with IS despite anticoagulation are a heterogeneous group with several possible mechanisms, which may include reduced or non-adherence to anticoagulation, competing non-cardioembolic stroke aetiologies or cardioembolic mechanisms separate from AF. The identification of one or more possible mechanisms of stroke despite anticoagulation may allow for a more targeted and individualised approach for secondary prevention. There are limited data to guide management in such patients, and strategies to prevent recurrent strokes include strict risk factor control and therapies targeting the most likely stroke mechanism. In cases where AF is suspected to be the culprit, clinical trials are needed to test the safety and efficacy of left atrial appendage occlusion plus anticoagulation versus continued anticoagulation alone.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Duncan Wilson
- Stroke Research Centre, UCL Institute of Neurology, London, UK
| | - David J Seiffge
- Department of Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
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17
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Lindhoff-Last E, Birschmann I, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Direct Oral Anticoagulants in Emergency Situations: Results of the Prospective Observational RADOA-Registry. Thromb Haemost 2021; 122:552-559. [PMID: 34256392 PMCID: PMC9113852 DOI: 10.1055/a-1549-6556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used worldwide. Little is known so far about their pharmacokinetics in emergency situations. METHODS A prospective, observational registry was performed to determine the clinical course in consecutive patients with major bleeding or urgent surgery treated with DOACs. In samples collected as part of routine care DOAC drug concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. Anticoagulant intensity at first presentation and drug half-life (t 1/2), tested in repeat samples, were evaluated. RESULTS A total of 140 patients were prospectively included. Pharmacokinetic data were available in 94% (132/140) of patients. Note that 67% (89/132) experienced life-threatening bleeding and 33% (43/132) needed an urgent surgery. For pharmacokinetic analysis a total of 605 blood samples was available. Median concentration on admission was 205 ng/mL for rivaroxaban and 108 ng/mL for apixaban. All treatment groups showed a high variation of drug concentrations at baseline. In rivaroxaban-treated patients t ½ was 17.3 hours (95% confidence interval [CI]: 15.4-19.7) without significant difference in both groups (major bleeding: t ½ 16.7 hours, 95% CI: 14.7-19.3; urgent surgery: t ½ 19.7 hours, 95% CI: 15.2-27.9; p = 0.292). In apixaban-treated patients t ½ was 25.0 hours (95% CI: 22.9-27.6) with a longer t ½ after urgent surgery (t 1/2: 30.8 hours; 95% CI: 26.9-36.4) compared with severe bleeding (t 1/2: 20.8 hours; 95% CI: 18.8-23.2; p < 0.001). CONCLUSION Emergency patients under DOAC treatment show a high variation of anticoagulant concentrations at baseline. Compared with rivaroxaban, apixaban showed a lower median concentration on admission and a longer t ½.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), Frankfurt, Germany,Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany,Address for correspondence Edelgard Lindhoff-Last, MD Cardiology Angiology Center Bethanien Hospital (CCB)Im Prüfling 23, 60389 FrankfurtGermany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1, Dresden, Germany,Division of Haematology, Dresden University Clinic, Dresden, Germany,Department of Haematology and Oncology, Kings College, London, United Kingdom
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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18
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Metze M, Klöter T, Stöbe S, Rechenberger B, Siegemund R, Siegemund T, Laufs U, Petros S, Pfrepper C. Plasma levels do not predict thrombin generation in patients taking direct oral anticoagulants. Int J Lab Hematol 2021; 43:1539-1548. [PMID: 34097808 DOI: 10.1111/ijlh.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The antithrombotic effect of direct oral anticoagulants (DOAC) in specific clinical scenarios is difficult to assess. OBJECTIVE This study aimed to evaluate the effect of DOAC on thrombin generation (TG) in relation to their plasma level. METHODS Eighty patients newly started on anticoagulation were included, 20 patients for each DOAC-apixaban, edoxaban, rivaroxaban, and dabigatran. Plasma was sampled before DOAC (baseline), at plasma peak time, 6 and 12 hours after starting DOAC for quantification of drug levels and TG. RESULTS The baseline TG before DOAC intake showed inter-individual variability. All DOACs significantly prolonged lag time (LT) and time to peak (TTP), but did not change endogenous thrombin potential (ETP). Anti-Xa inhibitors but not dabigatran reduced thrombin peak, but the effect of apixaban at plasma peak was less pronounced (factor 1.6). LT and TTP prolongation of dabigatran was lower compared to anti-Xa inhibitors. All DOACs showed a nonlinear dose-response relationship, with the greatest antithrombotic effect at lower DOAC plasma levels. The inhibition of TG parameters between baseline and peak was parallel between individual patients but the coefficient of variation of TG was lower compared to drug levels. CONCLUSION The antithrombotic effect at DOAC peak plasma level measured by TG depends on the patient-specific baseline TG level and the drug-specific inhibition by the particular DOAC. Although peak plasma levels have a high variability, the variation of TG is lower compared to drug levels. Therefore, TG assays may be superior to plasma levels in the assessment of the intensity of anticoagulation.
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Affiliation(s)
- Michael Metze
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Tristan Klöter
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Stöbe
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Ulrich Laufs
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical ICU, University Hospital Leipzig, Leipzig, Germany.,Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
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19
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Seiffge DJ, Wilson D, Wu TYH. Administering Thrombolysis for Acute Ischemic Stroke in Patients Taking Direct Oral Anticoagulants: To Treat or How to Treat. JAMA Neurol 2021; 78:515-516. [PMID: 33720313 DOI: 10.1001/jamaneurol.2021.0287] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital Bern, University Hospital Bern, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Yuan-Hao Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
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20
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Seiffge DJ, Meinel T, Purrucker JC, Kaesmacher J, Fischer U, Wilson D, Wu TY. Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:534-541. [PMID: 33542084 PMCID: PMC8053326 DOI: 10.1136/jnnp-2020-325456] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.
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Affiliation(s)
- David J Seiffge
- Stroke Research Center, Queen Square Institute of Neurology, London, UK .,Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | | | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric RadiologyUniversity Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Queen Square Institute of Neurology, London, UK.,Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Y Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
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21
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Seiffge DJ, Wilson D, Ambler G, Banerjee G, Hostettler IC, Houlden H, Shakeshaft C, Cohen H, Yousry TA, Al-Shahi Salman R, Lip G, Brown MM, Muir K, Jäger HR, Werring DJ. Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325299. [PMID: 33741739 PMCID: PMC8292570 DOI: 10.1136/jnnp-2020-325299] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/17/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We investigated the contribution of small vessel disease (SVD) to anticoagulant-associated intracerebral haemorrhage (ICH). METHODS Clinical Relevance of Microbleeds in Stroke-2 comprised two independent multicentre observation studies: first, a cross-sectional study of patients with ICH; and second, a prospective study of patients taking anticoagulants for atrial fibrillation (AF) after cerebral ischaemia. In patients with ICH, we compared SVD markers on CT and MRI according to prior anticoagulant therapy. In patients with AF and cerebral ischaemia treated with anticoagulants, we compared the rates of ICH and ischaemic stroke according to SVD burden score during 2 years follow-up. RESULTS We included 1030 patients with ICH (421 on anticoagulants), and 1447 patients with AF and cerebral ischaemia. Medium-to-high severity SVD was more prevalent in patients with anticoagulant-associated ICH (CT 56.1%, MRI 78.7%) than in those without prior anticoagulant therapy (CT 43.5%, p<0.001; MRI 64.5%, p=0.072). Leukoaraiosis and atrophy were more frequent and severe in ICH associated with prior anticoagulation. In the cerebral ischaemia cohort (779 with SVD), during 3366 patient-years of follow-up the rate of ICH was 0.56%/year (IQR 0.27-1.03) in patients with SVD, and 0.06%/year (IQR 0.00-0.35) in those without (p=0.001); ICH was independently associated with severity of SVD (HR 5.0, 95% CI 1.9 to 12.2,p=0.001), and was predicted by models including SVD (c-index 0.75, 95% CI 0.63 to 0.85). CONCLUSIONS Medium-to-high severity SVD is associated with ICH occurring on anticoagulants, and independently predicts ICH in patients with AF taking anticoagulants; its absence identifies patients at low risk of ICH. Findings from these two complementary studies suggest that SVD is a contributory factor in ICH in patients taking anticoagulants and suggest that anticoagulation alone should no longer be regarded as a sufficient 'cause' of ICH. TRIAL REGISTRATION NCT02513316.
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Affiliation(s)
- David J Seiffge
- Department of Neurology and Stroke Center, Inselspital Universitatsspital Bern, Bern, BE, Switzerland
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Duncan Wilson
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
- New Zealand Brain Research Institute, University of Otago, Christchurch, New Zealand
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, London, UK
| | - Gargi Banerjee
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | | | - Henry Houlden
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Clare Shakeshaft
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, London, UK
| | - Tarek A Yousry
- Neuroradiological Academic Unit, Department of Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, Edinburgh, UK
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, Merseyside, UK
- Aalborg Aalborg Thrombosis Research UnitThrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martin M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Keith Muir
- Institute of Neuroscience & Psychology, University of Glasgow and Queen Elizabeth University Hospital, Glasgow, UK
| | - H R Jäger
- Neuroradiological Academic Unit, Department of Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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22
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Coagulation Assay and Stroke Severity upon Admission of Patients with Cardioembolic Cerebral Infarction during Direct Oral Anticoagulant Use. Keio J Med 2021; 70:93-99. [PMID: 33731546 DOI: 10.2302/kjm.2020-0019-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Although the severity of acute cerebral infarction varies in patients receiving direct oral anticoagulants (DOACs), no practical method to predict the severity has been established. We analyzed retrospectively the relationship between cardioembolic cerebral infarction severity and coagulation indicators in patients treated with DOACs. We assessed the anticoagulation effect of DOACs using the activated partial thromboplastin time (APTT), prothrombin time (PT), and prothrombin time international standardized ratio (PT-INR) in 71 patients with cardioembolic cerebral infarction admitted to our hospital between January 2015 and December 2019. The participants were divided into a prolongation group (prolonged APTT for oral thrombin inhibitors or prolonged PT for oral factor Xa inhibitors, n =37) and a normal group (no prolongation of coagulation markers, n =34). Of the 71 patients, 21 (30%) and 50 (70%) were using oral thrombin and oral factor Xa inhibitors, respectively. PT, PT-INR, and APTT were significantly higher in the prolongation group (PT: 17.4 ± 5.1 vs. 12.8 ± 1.4 s, P < 0.001; PT-INR: 1.5 ± 0.5 vs. 1.1 ± 0.1, P < 0.001; APTT: 44.8 ± 26.4 vs. 30.4 ± 4.1 s, P = 0.003). The median National Institutes of Health Stroke Scale (NIHSS) score on admission and the prevalence of large vessel occlusion were significantly lower in the prolongation group (NIHSS: 2.0 vs. 9.5, P = 0.007; large vessel occlusion: 27% vs. 53%, P = 0.031). The prevalence of large vessel occlusion was low and stroke severity was mild in patients undergoing DOAC therapy with prolongation of coagulation assay markers upon onset of cardioembolic cerebral infarction.
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23
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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24
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Meinel TR, Branca M, De Marchis GM, Nedeltchev K, Kahles T, Bonati L, Arnold M, Heldner MR, Jung S, Carrera E, Dirren E, Michel P, Strambo D, Cereda CW, Bianco G, Kägi G, Vehoff J, Katan M, Bolognese M, Backhaus R, Salmen S, Albert S, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Schaerer M, Mono ML, Rodic B, Tarnutzer AA, Mordasini P, Gralla J, Kaesmacher J, Engelter S, Fischer U, Seiffge DJ. Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol 2020; 89:42-53. [PMID: 32996627 PMCID: PMC7756294 DOI: 10.1002/ana.25917] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes. METHODS This was a cohort study of consecutive patients (2014-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0-2) at 3 months. RESULTS Of 8,179 patients (mean [SD] age, 79.8 [9.6] years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, [interquartile range 2-11]) compared with VKA (6, [2-14]) and controls (7, [3-15], p < 0.001; quantile regression: β -2.1, 95% confidence interval [CI] -2.6 to -1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 [63%]; adjusted odds ratio [aOR] 0.67; 95% CI 0.50-0.90) and particularly in patients on DOACs (69 of 464 [15%]; aOR 0.06; 95% CI 0.05-0.08) compared with controls (1,544 of 2,504 [74%]). sICH after IVT occurred in 3.6% (2.6-4.7%) of controls, 9 of 195 (4.6%; 1.9-9.2%; aOR 0.93; 95% CI 0.46-1.90) patients on VKA and 2 of 65 (3.1%; 0.4-10.8%, aOR 0.56; 95% CI 0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3-month outcome (aOR 1.24; 1.01-1.51). INTERPRETATION Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42-53.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinicial Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabeth Dirren
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital Zurich, Basel, Switzerland
| | | | | | | | | | | | | | - Ludwig Schelosky
- Neurology, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Susanne Renaud
- Neurology, Cantonal Hospital Neuchatel, Neuchâtel, Switzerland
| | | | | | | | | | - Biljana Rodic
- Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatic Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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25
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Oberladstätter D, Voelckel W, Schlimp C, Zipperle J, Ziegler B, Grottke O, Schöchl H. A prospective observational study of the rapid detection of clinically-relevant plasma direct oral anticoagulant levels following acute traumatic injury. Anaesthesia 2020; 76:373-380. [PMID: 32946123 DOI: 10.1111/anae.15254] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/15/2022]
Abstract
In urgent clinical situations, such as trauma, urgent surgery or before thrombolysis, rapid quantification of direct oral anticoagulant plasma drug levels is warranted. Using the ClotPro® analyser, we assessed two novel viscoelastic tests for detection of clinically-relevant plasma drug levels in trauma patients. The ecarin clotting time was used to assess the plasma concentration of dabigatran and Russell´s viper venom clotting time to determine the plasma concentration of direct factor Xa inhibitors. In parallel, plasma concentrations were analysed using plasma-based chromogenic assays. A total of 203 simultaneous measurements were performed. Strong to very strong linear correlations were detected between ecarin clotting time and plasma concentration of dabigatran (r = 0.9693), and between Russell´s viper venom clotting time and plasma concentrations of apixaban (r = 0.7391), edoxaban (r = 0.9251) and rivaroxaban (r = 0.8792), all p < 0.001. An ecarin clotting time ≥ 189 seconds provided 100% sensitivity and 90% specificity for detecting plasma dabigatran concentrations ≥ 50 ng.ml-1 . Corresponding Russell´s viper venom clotting time cut-off values were ≥ 136 seconds for apixaban (80% sensitivity, 88% specificity), ≥ 168 seconds for edoxaban (100% sensitivity, 100% specificity) and ≥ 177 seconds for rivaroxaban (90% sensitivity, 100% specificity). Detection of drug levels ≥ 100 ng.ml-1 was also investigated: for dabigatran, an ecarin clotting time ≥ 315 seconds yielded 92% sensitivity and 100% specificity; while Russell´s viper venom clotting time cut-offs of 191, 188 and 196 seconds were calculated for apixaban (67% sensitivity, 88% specificity), edoxaban (100% sensitivity, 75% specificity) and rivaroxaban (100% sensitivity, 91% specificity), respectively. We have demonstrated strong positive correlations between plasma drug levels and clotting time values in the specific ClotPro assays. Cut-off values for detecting clinically-relevant drug levels showed high levels of sensitivity and specificity.
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Affiliation(s)
- D Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - W Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Schlimp
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - J Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - B Ziegler
- Department of Anaesthesiology and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - O Grottke
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - H Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
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26
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Saberwal B, Ioannou A, Lim WY, Beirne AM, Chow AW, Tousoulis D, Ahsan S, Papageorgiou N. Antithrombotic Therapy in Patients with Recent Stroke and Atrial Fibrillation. Curr Pharm Des 2020; 26:2715-2724. [DOI: 10.2174/1381612826666200407150307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
Abstract
:
Atrial fibrillation (AF) is a common arrhythmia which carries a significant risk of stroke. Secondary
prevention, particularly in the acute phase of stroke with anti-thrombotic therapy, has not been validated. The aim
of this review is to evaluate the available evidence on the use of antithrombotic therapy in patients with recent
stroke who have AF, and suggest a treatment algorithm for the various time points, taking into account both the
bleeding and thrombosis risks posed at each stage.
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Affiliation(s)
- Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Adam Ioannou
- Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Wei Y. Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anne-Marie Beirne
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anthony W. Chow
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
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27
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Kim HJ, Choi S, Kim HJ, Bang OY. Non-vitamin K oral antagonist failure and tailored treatment in patients with atrial fibrillation and stroke. PRECISION AND FUTURE MEDICINE 2020. [DOI: 10.23838/pfm.2020.00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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28
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Meinel TR, Kaesmacher J, Gralla J, Seiffge DJ, Auer E, Frey S, El-Koussy M, Arnold M, Fischer U, Göldlin M, Jung S, Hakim A. MRI characteristics in acute ischemic stroke patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists. BMC Neurol 2020; 20:86. [PMID: 32160909 PMCID: PMC7065352 DOI: 10.1186/s12883-020-01678-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background Despite the utility of neuroimaging in the diagnostic and therapeutic management of patients with acute ischemic stroke (AIS), imaging characteristics in patients with preceding direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) have hardly been described. We aimed to determine presence of large vessel occlusion (LVO), thrombus length, infarction diameter, and occurrence of hemorrhagic transformation in AIS patients with preceding DOAC as compared to VKA therapy. Methods Using a prospectively collected cohort of AIS patients, we performed univariate and multivariable regression analyses regarding imaging outcomes. Additionally, we provide a sensitivity analysis for the subgroup of patients with confirmed therapeutic anticoagulation. Results We included AIS in patients with preceding DOAC (N = 75) and VKA (N = 61) therapy, median age 79 (IQR 70–83), 39% female. Presence of any LVO between DOAC and VKA patients (29.3% versus 37.7%, P = 0.361), and target LVO for endovascular therapy (26.7% versus 27.9%, P = 1.0) was equal with a similar occlusion pattern. DOAC as compared to VKA were associated with a similar rate of target LVO for EVT (aOR 0.835, 95% CI 0.368–1.898). The presence of multiple lesions and characteristics of the thrombus were similar in DOAC and VKA patients. Acute ischemic lesion diameter in real world patients was equal in patients taking DOAC as compared to VKA. Lesion diameter in VKA patients (median 13 mm, IQR 6–26 versus median 20 mm, IQR 7–36, P = 0.001), but not DOAC patients was smaller in the setting of confirmed therapeutic VKA. The frequency of radiological hemorrhagic transformation and symptomatic intracranial hemorrhage in OAC patients was low. Sensitivity analysis considering only patients with confirmed therapeutic anticoagulation did not change any of the results. Conclusion Preceding DOAC treatment showed equal rates of LVO and infarct size as compared to VKA in AIS patients. This study adds to the knowledge of imaging findings in AIS patients with preceding anticoagulation.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland.
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Elias Auer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Sebastién Frey
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Marwan El-Koussy
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Martina Göldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland.,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, CH-3010, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Dias FA, Pontes-Neto OM, Seiffge DJ. Idarucizumab before reperfusion therapy in stroke patients on dabigatran: No more cold sweat. Neurology 2020; 94:811-812. [PMID: 32079736 DOI: 10.1212/wnl.0000000000009156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Francisco A Dias
- From Stroke Service (F.A.D., O.M.P.-N.), Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; and Department of Neurology (D.J.S.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
| | - Octávio M Pontes-Neto
- From Stroke Service (F.A.D., O.M.P.-N.), Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; and Department of Neurology (D.J.S.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - David J Seiffge
- From Stroke Service (F.A.D., O.M.P.-N.), Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; and Department of Neurology (D.J.S.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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30
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Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, Frey S, Goeldlin M, Mordasini P, Mosimann PJ, Nogueira RG, Haussen DC, Rodrigues GM, Uphaus T, L'Allinec V, Krajíčková D, Alonso A, Costalat V, Hajdu SD, Olivé-Gadea M, Maegerlein C, Pierot L, Schaafsma J, Suzuki K, Arnold M, Heldner MR, Fischer U, Kaesmacher J. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke 2020; 51:892-898. [PMID: 31992179 DOI: 10.1161/strokeaha.119.026606] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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Affiliation(s)
- Thomas R Meinel
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Joachim U Kniepert
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - David J Seiffge
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Simon Jung
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Elias Auer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Sebastién Frey
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Martina Goeldlin
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.).,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Raul G Nogueira
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Diogo C Haussen
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Gabriel M Rodrigues
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany, on behalf of the ENDOSTROKE Study Group (T.U.)
| | - Vincent L'Allinec
- Neuroradiology Department, Nantes University Hospital, France (V.L.)
| | - Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine in Hradec Králové, Charles University and University Hospital Hradec Králové, Czech Republic (D.K.)
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (A.A.)
| | | | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Switzerland (S.D.H.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | | | - Joanna Schaafsma
- Division of Neurology, University Health Network, University of Toronto, Canada (J.S.)
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan (K.S.)
| | - Marcel Arnold
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Mirjam R Heldner
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Urs Fischer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.)
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Artang R, Anderson M, Nielsen JD. Fully automated thromboelastograph TEG 6s to measure anticoagulant effects of direct oral anticoagulants in healthy male volunteers. Res Pract Thromb Haemost 2019; 3:391-396. [PMID: 31294326 PMCID: PMC6611480 DOI: 10.1002/rth2.12206] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/06/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The ability to assess the hemostatic effect of the direct oral anticoagulant (DOACs) may be valuable in clinical situations such as bleeding or thrombosis, before urgent surgery, or reversal of anticoagulation. We sought to assess the anticoagulant effect of DOACs with the new-generation fully automated thrombelastograph TEG 6s using resonance-frequency viscoelasticity measurements and disposable multichannel microfluidic cartridges. METHODS A single dose of oral dabigatran 150 mg, rivaroxaban 20 mg, or apixaban 5 mg was given to 9 healthy males. Phlebotomy was performed at 0, 1, and 3 hours after administration of DOAC. TEG parameters were measured using TEG _6s. Concentrations of DOACs were measured using chromogenic assays. The TEG parameters were correlated to the DOAC concentrations. RESULTS The reaction time (R) demonstrated the strongest response to DOAC intake. There were no correlations between other TEG parameters and DOAC concentrations. Using the direct thrombin inhibitor (DTI) channel, R was significantly correlated with dabigatran levels (r = 0.94, P < 0.0001). Using the anti-factor Xa (AFXa) channel, R was significantly correlated with rivaroxaban and apixaban levels (r = 0.93 and r = 0.83, respectively; P < 0.0001 for both). R >2.5 minutes for dabigatran (DTI channel), >2.5 minutes for apixaban, and >1.8 minutes for rivaroxaban (AFXa channel) were associated with 100% sensitivity and ≥ 90% specificity to detect DOAC levels of ≥ 50 ng/mL. CONCLUSION We have demonstrated that TEG _6s R has significant correlation with DOAC blood concentrations and has potential for monitoring the DOAC's effect on hemostasis with reasonable sensitivity in the small sample analyzed. This novel technology is easy to use on a small volume of whole blood without requiring a specialized laboratory. Further study is warranted to correlate R with clinical outcomes.
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Affiliation(s)
- Ramin Artang
- Essentia Health St. Mary's Heart and Vascular CenterDuluthMinnesota
- Bispebjerg University HospitalUniversity of CopenhagenKobenhavnDenmark
| | - Maren Anderson
- Essentia Health St. Mary's Heart and Vascular CenterDuluthMinnesota
- University of Minnesota School of MedicineMinneapolisMinnesota
| | - Jorn D. Nielsen
- Bispebjerg University HospitalUniversity of CopenhagenKobenhavnDenmark
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Abstract
PURPOSE OF REVIEW Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture. RECENT FINDINGS Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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Gerner ST, Kuramatsu JB, Sembill JA, Sprügel MI, Hagen M, Knappe RU, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Engelhorn T, Lücking H, Dörfler A, Schwab S, Huttner HB. Characteristics in Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 50:1392-1402. [PMID: 31092170 DOI: 10.1161/strokeaha.118.023492] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background and Purpose- Given inconclusive studies, it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage (ICH) related to vitamin K antagonists (VKA) versus non-vitamin K antagonist (NOAC)-related ICH. Notably, clinical characteristics according to different NOAC agents and dosages are not established. Methods- Multicenter observational cohort study integrating individual patient data of 1328 patients with oral anticoagulation-associated ICH, including 190 NOAC-related ICH patients, recruited from 2011 to 2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics, and 3-months modified Rankin Scale (mRS) outcomes were compared in NOAC- versus VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup analyses were performed regarding NOAC agent, dosing and present clinically relevant anticoagulatory activity (last intake <12h/24h or NOAC level >30 ng/mL). Results- Despite older age in NOAC patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median [interquartile range]: NOAC, 14.7 [5.1-42.3] mL versus VKA, 16.4 [5.8-40.6] mL; P=0.33), rate of hematoma expansion (NOAC, 49/146 [33.6%] versus VKA, 235/688 [34.2%]; P=0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS, 4-6: NOAC 126/179 [70.4%] versus VKA 473/682 [69.4%]; P=0.79). Subgroup analyses revealed that NOAC patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (n/N [%]: present 52/109 [47.7%] versus absent 9/35 [25.7%]; P=0.022) and hematoma expansion (present 35/90 [38.9%] versus absent 5/30 [16.7%]; P=0.040), whereas type of NOAC agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusions- If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03093233.
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Affiliation(s)
- Stefan T Gerner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Joji B Kuramatsu
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Jochen A Sembill
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Maximilian I Sprügel
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Manuel Hagen
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Ruben U Knappe
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Matthias Endres
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße, Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin (M.E.)
| | - Karl Georg Haeusler
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Jan Sobesky
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Johannes Schurig
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Sarah Zweynert
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Peter Vajkoczy
- Department of Neurosurgery (P.V.), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | | | - Jörg Glahn
- Department of Neurology and Neurogeriatry (P.D.S., J.G.)
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, University Clinic Ruhr University Bochum, Germany (U.J.K.)
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld).,Department of Neurology, LVR Klinik Bonn, Germany (C.D.)
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig).,Department of Neurology, Klinikum Augsburg, Germany (H. Schneider)
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Otto W Witte
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Albrecht Günther
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany (J.F.H.)
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hagen B Huttner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
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Seiffge DJ, Paciaroni M, Wilson D, Koga M, Macha K, Cappellari M, Schaedelin S, Shakeshaft C, Takagi M, Tsivgoulis G, Bonetti B, Kallmünzer B, Arihiro S, Alberti A, Polymeris AA, Ambler G, Yoshimura S, Venti M, Bonati LH, Muir KW, Yamagami H, Thilemann S, Altavilla R, Peters N, Inoue M, Bobinger T, Agnelli G, Brown MM, Sato S, Acciarresi M, Jager HR, Bovi P, Schwab S, Lyrer P, Caso V, Toyoda K, Werring DJ, Engelter ST, De Marchis GM. Direct oral anticoagulants versus vitamin K antagonists after recent ischemic stroke in patients with atrial fibrillation. Ann Neurol 2019; 85:823-834. [PMID: 30980560 PMCID: PMC6563449 DOI: 10.1002/ana.25489] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/04/2023]
Abstract
Objective We compared outcomes after treatment with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and a recent cerebral ischemia. Methods We conducted an individual patient data analysis of seven prospective cohort studies. We included patients with AF and a recent cerebral ischemia (<3 months before starting oral anticoagulation) and a minimum follow‐up of 3 months. We analyzed the association between type of anticoagulation (DOAC versus VKA) with the composite primary endpoint (recurrent ischemic stroke [AIS], intracerebral hemorrhage [ICH], or mortality) using mixed‐effects Cox proportional hazards regression models; we calculated adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Results We included 4,912 patients (median age, 78 years [interquartile range {IQR}, 71–84]; 2,331 [47.5%] women; median National Institute of Health Stroke Severity Scale at onset, 5 [IQR, 2–12]); 2,256 (45.9%) patients received VKAs and 2,656 (54.1%) DOACs. Median time from index event to starting oral anticoagulation was 5 days (IQR, 2–14) for VKAs and 5 days (IQR, 2–11) for DOACs (p = 0.53). There were 262 acute ischemic strokes (AISs; 4.4%/year), 71 intracranial hemorrrhages (ICHs; 1.2%/year), and 439 deaths (7.4%/year) during the total follow‐up of 5,970 patient‐years. Compared to VKAs, DOAC treatment was associated with reduced risks of the composite endpoint (HR, 0.82; 95% CI, 0.67–1.00; p = 0.05) and ICH (HR, 0.42; 95% CI, 0.24–0.71; p < 0.01); we found no differences for the risk of recurrent AIS (HR, 0.91; 95% CI, 0.70–1.19; p = 0.5) and mortality (HR, 0.83; 95% CI, 0.68–1.03; p = 0.09). Interpretation DOAC treatment commenced early after recent cerebral ischemia related to AF was associated with reduced risk of poor clinical outcomes compared to VKA, mainly attributed to lower risks of ICH. ANN NEUROL 2019;85:823–834.
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Affiliation(s)
- David J Seiffge
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Duncan Wilson
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Manuel Cappellari
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Clare Shakeshaft
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens School of Medicine, "Attikon" University Hospital, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Bruno Bonetti
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Shoji Arihiro
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alexandros A Polymeris
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, UCL, London, United Kingdom
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Leo H Bonati
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Hiroshi Yamagami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sebastian Thilemann
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Riccardo Altavilla
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Nils Peters
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tobias Bobinger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Martin M Brown
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Hans Rolf Jager
- Neuroradiological Academic Unit, Department of Brain Repair & Rehabilitation, University College London, Institute of Neurology, London, United Kingdom
| | - Paolo Bovi
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - David J Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Stefan T Engelter
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants - A systematic review. PLoS One 2019; 14:e0213379. [PMID: 30925155 PMCID: PMC6440627 DOI: 10.1371/journal.pone.0213379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background Non-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce. Objective Systematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis. Data sources PubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018. Study eligibility criteria 52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients. Study appraisal and synthesis method We systematically assessed study quality using a bias tool and pooled consistent data. Results Existing data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging. Limitations Limited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings. Conclusions Acute ischemic events despite treatment with NOAC therapy are insufficiently investigated. Systematic review registration number PROSPERO: CRD42018074853.
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Best JG, Bell R, Haque M, Chandratheva A, Werring DJ. Atrial fibrillation and stroke: a practical guide. Pract Neurol 2019; 19:208-224. [PMID: 30826740 DOI: 10.1136/practneurol-2018-002089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neurologists and stroke physicians will be familiar with atrial fibrillation as a major cause of ischaemic stroke, and the role of anticoagulation in preventing cardioembolic stroke. However, making decisions about anticoagulation for individual patients remains a difficult area of clinical practice, balancing the serious risk of ischaemic stroke against that of major bleeding, particularly intracranial haemorrhage. Atrial fibrillation management requires interdisciplinary collaboration with colleagues in cardiology and haematology. Recent advances, especially the now-widespread availability of direct oral anticoagulants, have brought opportunities to improve stroke care while posing new challenges. This article gives an overview of the contemporary diagnosis and management of atrial fibrillation, and the associated evidence base. Where there is uncertainty, we describe our own approach to these areas, while highlighting ongoing research that will likely guide future practice.
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Affiliation(s)
- Jonathan Gordon Best
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK
| | - Robert Bell
- Institute of Cardiovascular Science, University College London, London, UK
| | - Mohammed Haque
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - David John Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK .,Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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Sennesael AL, Larock AS, Douxfils J, Elens L, Stillemans G, Wiesen M, Taubert M, Dogné JM, Spinewine A, Mullier F. Rivaroxaban plasma levels in patients admitted for bleeding events: insights from a prospective study. Thromb J 2018; 16:28. [PMID: 30455596 PMCID: PMC6231259 DOI: 10.1186/s12959-018-0183-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/21/2018] [Indexed: 11/17/2022] Open
Abstract
Background Serious bleeding events have been frequently described in patients taking direct oral anticoagulants (DOAC). In secondary analyses of phase 3 trials, DOAC plasma concentrations were shown to correlate with bleeding outcomes. This study aimed to describe rivaroxaban plasma levels in patients admitted to the emergency department (ED) for bleeding events. For each patient, risk factors for experiencing bleeding events were also investigated. Methods This analysis was part of an observational study conducted in the ED of two teaching hospitals. Plasma samples from 10 rivaroxaban-treated patients admitted for bleeding events were collected. Rivaroxaban plasma concentrations were determined by calibrated chromogenic anti-Xa assay. The measured rivaroxaban levels were then extrapolated at trough using a published population pharmacokinetic (PopPK) model, and compared to on-therapy ranges observed in large clinical trials. For each patient, clinical, medication and ABCB1 genotype data were collected. Results Rivaroxaban measurements varied from 5 to 358 ng/ml, with a post-intake delay ranging from 9 to 38 h. At trough, estimated plasma concentrations were between 12 and 251 ng/ml (median value 94 ng/ml). Four patients had higher-than-expected rivaroxaban levels. Inadequate dose regimen, excessive alcohol consumption and lack of treatment reassessment were observed in several patients. Half of patients were taking ≥1 drug with potential pharmacokinetics interactions (e.g. amiodarone, diltiazem), while half of patients were taking ≥1 drug increasing the risk of bleeding. All 3 patients with available genotyping data and higher-than-expected rivaroxaban levels were heterozygous or homozygous mutated for the ABCB1 1236C > T, 2677G > T, 3435 C > T and rs4148738 single nucleotide polymorphisms (SNP). Conclusions Rivaroxaban patients admitted to the ED for bleeding events showed highly variable plasma concentrations. This analysis underlines the usefulness of rapid DOAC measurement and the value of PopPK models to estimate concentrations at trough in a context where the post-intake delay is unmanageable. Close patient follow-up, including renal function assessment and drug interactions review, is essential for bleeding risk minimization.
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Affiliation(s)
- Anne-Laure Sennesael
- 1Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne-Sophie Larock
- 2CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - Jonathan Douxfils
- 3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Laure Elens
- 4Louvain Drug Research Institute, Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Université catholique de Louvain, Brussels, Belgium
| | - Gabriel Stillemans
- 4Louvain Drug Research Institute, Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Université catholique de Louvain, Brussels, Belgium
| | - Martin Wiesen
- 5Center of Pharmacology, Therapeutic Drug Monitoring Unit, University Hospital of Cologne, Cologne, Germany
| | - Max Taubert
- 6Center of Pharmacology, Clinical Pharmacology Unit, University Hospital of Cologne, Cologne, Germany
| | - Jean-Michel Dogné
- 3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne Spinewine
- 1Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,2CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - François Mullier
- 7CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Université catholique de Louvain, Yvoir, Belgium
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Wada S, Toyoda K, Sato S, Matsuki T, Okata T, Kumamoto M, Tagawa N, Inoue M, Okamoto A, Ihara M, Kitazono T, Miyata T, Koga M. Anti-Xa Activity and Event Risk in Patients With Direct Factor Xa Inhibitors Initiated Early After Stroke. Circ J 2018; 82:2872-2879. [DOI: 10.1253/circj.cj-18-0506] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takayuki Matsuki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takuya Okata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masaya Kumamoto
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Naoki Tagawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Akira Okamoto
- Divion of Clinical Chemistry, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Seiffge DJ, Polymeris AA, Fladt J, Lyrer PA, Engelter ST, De Marchis GM. Management of patients with stroke treated with direct oral anticoagulants. J Neurol 2018; 265:3022-3033. [PMID: 30293111 DOI: 10.1007/s00415-018-9061-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/13/2018] [Indexed: 12/14/2022]
Abstract
Since their market approval, direct oral anticoagulants (DOACs) are being increasingly used for stroke prevention in patients with atrial fibrillation. However, the management of DOAC-treated patients with stroke poses several challenges for physicians in everyday clinical practice, both in the acute setting and in long-term care. This has spurred extensive research activity in the field over the past few years, which we review here.
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Affiliation(s)
- D J Seiffge
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - A A Polymeris
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - J Fladt
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - P A Lyrer
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - S T Engelter
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
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Tala M, Paoletti O, Dellanoce C, Morandini R, Valtulina C, Sessa M, Testa S. Dabigatran Plasma Measurement to Guide the Management of Acute Bleeding and Thrombotic Complications. Eur J Case Rep Intern Med 2018; 5:000947. [PMID: 30756068 PMCID: PMC6346816 DOI: 10.12890/2018_000947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/28/2018] [Indexed: 01/01/2023] Open
Abstract
Oral anticoagulant therapy is recommended for the prevention and treatment of venous thromboembolism and to prevent stroke in non-valvular atrial fibrillation. Until a few years ago, vitamin K antagonists were the only drugs available, but direct oral anticoagulants have recently been introduced into clinical practice for the same clinical indications. Unlike the situation with VKAs, fixed-dose administration was proposed for DOACs, without the necessity for routine laboratory monitoring. However, in clinical practice a high inter-variability in DOAC plasma levels, independently of the type of drug and patient characteristics, was observed and the importance of measuring DOAC anticoagulant activity to support treatment decisions has therefore been recognized. We describe two clinical cases in order to highlight the role and importance of dabigatran-specific measurements to guide patient management in case of major complications. LEARNING POINT Direct oral anticoagulants (DOACs) have been used in clinical practice at fixed doses without laboratory monitoring.However, the importance of measuring DOAC anticoagulant activity to support treatment decisions, particularly in emergency conditions, has been recognized.The clinical value of DOAC measurement is highlighted in the two described cases where the anticoagulation level was taken into consideration when deciding on treatment.
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Affiliation(s)
- Maurizio Tala
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
| | - Oriana Paoletti
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
| | | | | | | | - Maria Sessa
- Division of Neurology, ASST Cremona, Cremona, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
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Lyden PD. When less is more (brain)-comment on "Rivaroxaban plasma levels in acute ischemic stroke and intracerebral hemorrhage". Ann Neurol 2018; 83:446-448. [PMID: 29394506 DOI: 10.1002/ana.25163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/30/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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