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Vasquez MA, Lambrakos LK, Velasquez A, Goldberger JJ, Mitrani RD. Contemporary outcomes of acute ischemic stroke in atrial fibrillation patients on anticoagulation. J Stroke Cerebrovasc Dis 2024; 33:107790. [PMID: 38788986 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Long-term anticoagulation (AC) therapy reduces the risk of stroke in patients with Atrial Fibrillation (AF). However, data on the impact of AC on in-hospital stroke outcomes is lacking. METHODS The National Inpatient Sample was used to identify adult inpatients with AF and a primary diagnosis of ischemic stroke between 2016 and 2020. Data was stratified between AC users and nonusers. A multivariate regression model was used to describe the in-hospital outcomes, adjusting for significant comorbidities. RESULTS A total of 655,540 hospitalizations with AF and a primary hospitalization diagnosis of ischemic stroke were included, of which 194,560 (29.7 %) were on long-term AC. Patients on AC tended to be younger (mean age, 77 vs. 78), had a higher average CHA2DS2VASc score (4.48 vs. 4.20), higher rates of hypertension (91 % vs. 88 %), hyperlipidemia (64 % vs. 59 %), and heart failure (34 % vs. 30 %) compared to patients not on long-term AC. Use of AC was associated with decreased in-hospital mortality (aOR [95 % CI]: 0.62 [0.60-0.63]), decreased stroke severity (mean NIHSS, 8 vs. 10), decreased use of tPA (aOR 0.42 [0.41-0.43]), mechanical thrombectomy (aOR 0.85 [0.83-0.87]), intracranial hemorrhage (aOR 0.69 [0.67-0.70]), gastrointestinal bleeding (aOR 0.74 [0.70-0.77]), and discharge to skilled nursing facilities (aOR 0.90 [0.89-0.91]), compared to patients not on AC (P<0.001 for all comparisons). CONCLUSION Among patients with AF admitted for acute ischemic stroke, AC use prior to stroke was associated with decreased in-hospital mortality, decreased stroke severity, decreased discharge to SNF, and fewer stroke-related and bleeding complications.
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Affiliation(s)
- Moises A Vasquez
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, C-600D, Miami, FL 33136, USA.
| | - Litsa K Lambrakos
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alex Velasquez
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jeffrey J Goldberger
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Raul D Mitrani
- Department of Medicine, Department of Cardiovascular Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
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Sawczyńska K, Włodarczyk E, Pawlicka A, Kołodziejczyk B, Wrona P, Wężyk K, Homa T, Sarba P, Wróbel D, Zdrojewska K, Sobolewska M, Rolkiewicz D, Slowik A. Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes. Stroke Res Treat 2024; 2024:2285722. [PMID: 38371464 PMCID: PMC10874293 DOI: 10.1155/2024/2285722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. Materials and Methods In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). Results In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.
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Affiliation(s)
- Katarzyna Sawczyńska
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Ewa Włodarczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Bartosz Kołodziejczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Wrona
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Kamil Wężyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Physiotherapy, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Dominik Wróbel
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Kaja Zdrojewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Maria Sobolewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Dawid Rolkiewicz
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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3
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Bernegger A, Mikšová D, Posekany A, Krebs S, Ferrari J, Greisenegger S, Gattringer T, Lang W, Kiechl S, Sykora M. Time trends in stroke severity in the years 2005 to 2020: results from the Austrian Stroke Unit Registry. J Neurol 2022; 269:4396-4403. [PMID: 35307755 DOI: 10.1007/s00415-022-11079-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE With aging population, there is an increase of atrial fibrillation (AF) and other vascular risk factors. We investigated trends in stroke severity at hospital admission with respect to AF and other risk factors in a prospective national stroke registry from 2005 to 2020. METHODS Data from the prospective Austrian Stroke Unit Registry were used to study demographic and clinical factors associated with the change in admission stroke severity over years. Time trends in admission stroke severity of patients with pre-stroke modified Rankin Score ≤ 3 were investigated with respect to clinical variables and predefined age groups 18-54, 55-64, 65-74, 75-84 and ≥ 85 years. Time trends were studied using robust generalized linear models assuming normal distribution with a log link. Stroke severity on admission was assessed according to the National Institutes of Health Stroke Scale Score (NIHSS). RESULTS In total, 140,312 patients with acute ischemic stroke were included in the analysis. Within the study period, mean patients' age increased from 70 to 72 years (p < 0.001) and median NIHSS at admission decreased from 4 to 3 (p < 0.001). The frequency of AF increased from 25 to 32% (p < 0.001). The decrease in median admission NIHSS was evident in all relevant subgroups but more pronounced in patients with risk factors including AF, diabetes, hypercholesterolemia, smoking, elderly patients and those with pre-stroke disability. CONCLUSION Despite an aging population and generally increasing AF frequency, we observed a consistent trend towards less disabling strokes on admission.
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Affiliation(s)
| | | | - Alexandra Posekany
- Gesundheit Österreich GmbH/BIQG, Vienna, Austria.,Research Unit of Computational Statistics, University of Technology, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.,VASCage, Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria. .,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria.
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4
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Vinding NE, Butt JH, Olesen JB, Xian Y, Kristensen SL, Rørth R, Bonde AN, Gundlund A, Yafasova A, Weeke PE, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Association Between Inappropriately Dosed Anticoagulation Therapy With Stroke Severity and Outcomes in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024402. [PMID: 35229642 PMCID: PMC9075280 DOI: 10.1161/jaha.121.024402] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Oral anticoagulation (OAC) is effective for stroke prevention in patients with atrial fibrillation. However, some patients experience stroke despite OAC therapy, and knowledge about the impact of prior treatment quality is lacking. Methods and Results Patients with atrial fibrillation on OAC therapy who had a first‐time ischemic stroke were identified in the Danish Stroke Registry (2005–2018). Patients treated with vitamin K antagonist (VKA) therapy were compared according to the international normalized ratio just before stroke (international normalized ratio <2 [subtherapeutic], international normalized ratio 2–3 [therapeutic], international normalized ratio >3 [supratherapeutic]), and patients on underdosed, appropriately dosed, and overdosed direct OAC (DOAC) therapy were compared. Stroke severity was determined using the Scandinavia Stroke Scale (0–58 points), and the risk of very severe stroke (0–14 points) was analyzed by multivariable logistic regression. One‐year mortality was determined using multivariable Cox regression. A total of 2319 patients with atrial fibrillation and stroke were included; 1196 were taking a VKA (subtherapeutic [46%], therapeutic [43%], supratherapeutic [11%]), and 1123 were taking DOAC (underdosed [23%], appropriately dosed [60%], and overdosed [17%]). Subtherapeutic and supratherapeutic VKA therapy (compared with therapeutic) and underdosed DOAC therapy (compared with appropriate and underdosed DOAC) patients were older, more often women, and more comorbid. Subtherapeutic VKA therapy was associated with very severe stroke (odds ratio [OR], 2.06 [95% CI, 1.28–3.31]), whereas supratherapeutic VKA therapy was not (OR, 1.24 [95% CI, 0.60–2.57]) compared with therapeutic VKA therapy. Patients on subtherapeutic and supratherapeutic VKA therapy had a higher 1‐year mortality (hazard ratio [HR], 1.66 [95% CI, 1.29–2.13]); HR, 1.55 [95% CI, 1.08–2.22], respectively) than those on therapeutic VKA therapy. Treatment with underdosed or overdosed DOAC therapy was not associated with very severe stroke (OR, 1.27 [95% CI, 0.76–2.15]; OR, 0.73 [95% CI, 0.37–1.43], respectively) and was not associated with 1‐year mortality (HR, 1.09 [95% CI, 0.83–1.44]; HR, 0.82 [95% CI, 0.57–1.18], respectively) than appropriate DOAC. Conclusions Half of the patients with atrial fibrillation with stroke were on inappropriate OAC therapy. Subtherapeutic VKA was associated with worse stroke severity and higher mortality rate than therapeutic VKA therapy. Neither underdosed nor overdosed DOAC was associated with worse outcomes in adjusted models compared with appropriately dosed DOAC. This study supports DOAC as a first‐line therapy over VKA.
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Affiliation(s)
- Naja E Vinding
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jawad H Butt
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jonas B Olesen
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Ying Xian
- Department of Neurology University of Texas Southwestern Medical Center Dallas TX
| | - Søren Lund Kristensen
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Rasmus Rørth
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Anders Nissen Bonde
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Anna Gundlund
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark.,Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Adelina Yafasova
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Peter E Weeke
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Gunnar H Gislason
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark.,The Danish Heart Foundation Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation Nordsjællands Hospital Hillerød Denmark.,Department of Cardiology Aalborg University Hospital Aalborg Denmark.,Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Emil L Fosbøl
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
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5
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Bieber M, Foerster KI, Haefeli WE, Pham M, Schuhmann MK, Kraft P. Treatment with Edoxaban Attenuates Acute Stroke Severity in Mice by Reducing Blood-Brain Barrier Damage and Inflammation. Int J Mol Sci 2021; 22:ijms22189893. [PMID: 34576055 PMCID: PMC8464921 DOI: 10.3390/ijms22189893] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with atrial fibrillation and previous ischemic stroke (IS) are at increased risk of cerebrovascular events despite anticoagulation. In these patients, treatment with non-vitamin K oral anticoagulants (NOAC) such as edoxaban reduced the probability and severity of further IS without increasing the risk of major bleeding. However, the detailed protective mechanism of edoxaban has not yet been investigated in a model of ischemia/reperfusion injury. Therefore, in the current study we aimed to assess in a clinically relevant setting whether treatment with edoxaban attenuates stroke severity, and whether edoxaban has an impact on the local cerebral inflammatory response and blood–brain barrier (BBB) function after experimental IS in mice. Focal cerebral ischemia was induced by transient middle cerebral artery occlusion in male mice receiving edoxaban, phenprocoumon or vehicle. Infarct volumes, functional outcome and the occurrence of intracerebral hemorrhage were assessed. BBB damage and the extent of local inflammatory response were determined. Treatment with edoxaban significantly reduced infarct volumes and improved neurological outcome and BBB function on day 1 and attenuated brain tissue inflammation. In summary, our study provides evidence that edoxaban might exert its protective effect in human IS by modulating different key steps of IS pathophysiology, but further studies are warranted.
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Affiliation(s)
- Michael Bieber
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.I.F.); (W.E.H.)
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.I.F.); (W.E.H.)
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, 97080 Würzburg, Germany;
| | - Michael K. Schuhmann
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
| | - Peter Kraft
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
- Department of Neurology, Klinikum Main-Spessart, 97816 Lohr, Germany
- Correspondence: ; Tel.: +49-9352-505-1501
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6
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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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7
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Cho HJ, Kang YJ, Sung SM, Ahn SH, Jung YH, Lee KY, Seo JH, Han SW, Park JH, Choi HY, Kwon JH, Kim WJ, Park HJ, Choi JK, Nam HS, Heo JH, Kim YD. Effects of dabigatran and rivaroxaban on stroke severity according to the results of routine coagulation tests. PLoS One 2020; 15:e0240483. [PMID: 33044991 PMCID: PMC7549802 DOI: 10.1371/journal.pone.0240483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Prior use of direct oral anticoagulants has been associated with reduced stroke severity in patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the impact of prothrombin time (PT) and activated partial thromboplastin time (aPTT) on stroke severity in patients who were receiving dabigatran or rivaroxaban at the time of stroke onset. Materials and methods We enrolled 107 patients with NVAF who developed acute ischemic stroke while on dabigatran or rivaroxaban and presented within 24 hours to nine hospitals between January 2014 and December 2018. The results of PT and aPTT assays were obtained within 24 hours of stroke onset in all patients. We analyzed PT and aPTT in relation to stroke severity and ischemic lesion volume using correlation and multivariable regression analyses. Results Of the 107 patients included, 46 (43.0%) were on dabigatran and 61 (57.0%) were on rivaroxaban. In patients with prior dabigatran use, while aPTT was inversely correlated with admission National Institutes of Health Stroke Scale (NIHSS) score (r = -0.369, p = 0.012) and ischemic lesion volume (r = -0.480, p = 0.005), there was no correlation between PT and either of these variables. Multivariable analysis confirmed the existence of a significant independent inverse relationship between aPTT and NIHSS score at admission (B, -0.201; 95% confidence interval [CI], -0.370 to -0.032; p = 0.005) and between aPTT and ischemic lesion volume (B, -0.076; 95% CI, -0.130 to -0.023; p = 0.007). In patients with prior rivaroxaban use, neither PT nor aPTT was associated with admission NIHSS score or ischemic lesion volume in the correlation and multivariable analyses. Conclusions In patients with NVAF who were receiving dabigatran, prolonged aPTT was associated with reduced stroke severity.
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Affiliation(s)
- Han-Jin Cho
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Yoon Jung Kang
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Sang Min Sung
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Sung-Ho Ahn
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Yo Han Jung
- Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang Won Han
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Joong Hyun Park
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Hyung Jong Park
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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8
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Narita N, Okumura K, Kinjo T, Mikami J, Tsushima K, Takahashi R, Noro M, Hashimoto A, Sasaki T, Takaki M, Ishidoya E, Narita Y, Imai H, Ono E, Tomita H. Trends in Prevalence of Non-Valvular Atrial Fibrillation and Anticoagulation Therapy in a Japanese Region ― Analysis Using the National Health Insurance Database ―. Circ J 2020; 84:706-713. [DOI: 10.1253/circj.cj-18-0989] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Noritomo Narita
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Joko Mikami
- Department of Health and Welfare, Hirosaki City
| | | | | | - Makiko Noro
- Department of Health and Welfare, Hirakawa City
| | | | | | | | | | | | | | - Emiko Ono
- Department of Welfare, Inakadate Village
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine
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9
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Tokunaga K, Koga M, Itabashi R, Yamagami H, Todo K, Yoshimura S, Kimura K, Sato S, Terasaki T, Inoue M, Shiokawa Y, Takagi M, Kamiyama K, Tanaka K, Takizawa S, Shiozawa M, Okuda S, Okada Y, Kameda T, Nagakane Y, Hasegawa Y, Shibuya S, Ito Y, Matsuoka H, Takamatsu K, Nishiyama K, Kario K, Yagita Y, Fujita K, Ando D, Kumamoto M, Arihiro S, Toyoda K. Prior Anticoagulation and Short- or Long-Term Clinical Outcomes in Ischemic Stroke or Transient Ischemic Attack Patients With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2020; 8:e010593. [PMID: 30691339 PMCID: PMC6405591 DOI: 10.1161/jaha.118.010593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background We aimed to clarify associations between prior anticoagulation and short‐ or long‐term clinical outcomes in ischemic stroke or transient ischemic attack patients with nonvalvular atrial fibrillation. Methods and Results A total of 1189 ischemic stroke or transient ischemic attack patients with nonvalvular atrial fibrillation who were hospitalized within 7 days after onset were analyzed. Of these, 813 patients (68.4%) received no prior anticoagulation, 310 (26.1%) received prior warfarin treatment with an international normalized ratio (INR) <2 on admission, 28 (2.4%) received prior warfarin treatment with an INR ≥2 on admission, and the remaining 38 (3.2%) received prior direct oral anticoagulant treatment. Prior warfarin treatment was associated with a lower risk of death or disability at 3 months compared with no prior anticoagulation (INR <2: adjusted odds ratio: 0.58; 95% CI, 0.42–0.81; P=0.001; INR ≥2: adjusted odds ratio: 0.40; 95% CI, 0.16–0.97; P=0.043) but was not associated with a lower risk of death or disability at 2 years. Prior warfarin treatment with an INR ≥2 on admission was associated with a higher risk of ischemic events within 2 years compared with no prior anticoagulation (adjusted hazard ratio: 2.94; 95% CI, 1.20–6.15; P=0.021). Conclusions Prior warfarin treatment was associated with a lower risk of death or disability at 3 months but was not associated with a lower risk of death or disability at 2 years in ischemic stroke or transient ischemic attack patients with nonvalvular atrial fibrillation. Prior warfarin treatment with an INR ≥2 on admission was associated with a higher risk of ischemic events within 2 years. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01581502.
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Affiliation(s)
- Keisuke Tokunaga
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masatoshi Koga
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Ryo Itabashi
- 3 Department of Stroke Neurology Kohnan Hospital Sendai Japan
| | - Hiroshi Yamagami
- 2 Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Kenichi Todo
- 4 Department of Neurology Osaka University Graduate School of Medicine Suita Japan
| | - Sohei Yoshimura
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kazumi Kimura
- 5 Department of Neurological Science Graduate School of Medicine Nippon Medical School Tokyo Japan
| | - Shoichiro Sato
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tadashi Terasaki
- 6 Department of Neurology Japanese Red Cross Kumamoto Hospital Kumamoto Japan
| | - Manabu Inoue
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Yoshiaki Shiokawa
- 7 Departments of Neurosurgery and Stroke Center Kyorin University School of Medicine Mitaka Japan
| | - Masahito Takagi
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kenji Kamiyama
- 8 Department of Neurosurgery Nakamura Memorial Hospital Sapporo Japan
| | - Kanta Tanaka
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunya Takizawa
- 9 Department of Neurology Tokai University School of Medicine Isehara Japan
| | - Masayuki Shiozawa
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Satoshi Okuda
- 10 Department of Neurology NHO Nagoya Medical Center Nagoya Japan
| | - Yasushi Okada
- 11 Department of Neurology and Cerebrovascular Medicine NHO Kyushu Medical Center Fukuoka Japan
| | - Tomoaki Kameda
- 12 Division of Neurology Jichi Medical University School of Medicine Shimotsuke Japan
| | | | - Yasuhiro Hasegawa
- 15 Department of Neurology St Marianna University School of Medicine Kawasaki Japan
| | - Satoshi Shibuya
- 16 Department of Neurology South Miyagi Medical Center Ogawara Japan
| | - Yasuhiro Ito
- 17 Department of Neurology TOYOTA Memorial Hospital Toyota Japan
| | - Hideki Matsuoka
- 18 Department of Cerebrovascular Medicine NHO Kagoshima Medical Center Kagoshima Japan
| | - Kazuhiro Takamatsu
- 19 Department of Neurology Brain Attack Center Ota Memorial Hospital Fukuyama Japan
| | - Kazutoshi Nishiyama
- 20 Department of Neurology Kitasato University School of Medicine Sagamihara Japan
| | - Kazuomi Kario
- 13 Division of Cardiovascular Medicine Jichi Medical University School of Medicine Shimotsuke Japan
| | - Yoshiki Yagita
- 21 Department of Stroke Medicine Kawasaki Medical School Kurashiki Japan
| | - Kyohei Fujita
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Daisuke Ando
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masaya Kumamoto
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shoji Arihiro
- 2 Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- 1 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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10
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Multicenter Prospective Analysis of Stroke Patients Taking Oral Anticoagulants: The PASTA Registry - Study Design and Characteristics. J Stroke Cerebrovasc Dis 2019; 28:104456. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/30/2019] [Accepted: 09/27/2019] [Indexed: 12/22/2022] Open
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11
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Song TJ, Baek IY, Woo HG, Kim YJ, Chang Y, Kim BJ, Heo SH, Jung JM, Oh K, Kim CK, Yu S, Park KY, Kim JM, Park JH, Choi JC, Park MS, Kim JT, Choi KH, Hwang YH, Chung JW, Bang OY, Kim GM, Seo WK. Characteristics and Factors for Short-Term Functional Outcome in Stroke Patients With Atrial Fibrillation, Nationwide Retrospective Cohort Study. Front Neurol 2019; 10:1101. [PMID: 31681159 PMCID: PMC6813464 DOI: 10.3389/fneur.2019.01101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/01/2019] [Indexed: 01/07/2023] Open
Abstract
Background and aims: Atrial fibrillation (AF) is a major cause of ischemic stroke; however, detailed clinical data and prognostic factors for stroke patients with AF are lacking in Korea. We aimed to investigate clinical information and factors associated with functional outcomes of stroke patients with AF from the Korean nationwide ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) database. Methods: From January 2013 to December 2015, consecutive clinical information from acute stroke patients with AF or history of AF was collected from 11 centers in Korea. Collected data included demographics, risk factors, pre-stroke medication, stroke severity, stroke subtypes, concomitant cerebral atherosclerosis, brain image findings, recanalization therapy, discharge medication, and functional outcome at 3 months after index stroke. Results: A total of 3,213 stroke patients (mean age, 73.6 ± 9.8 years; female, 48.6%) were included. The mean CHA2DS2-VASc score was 4.9. Among the 1,849 (57.5%) patients who had brain image and functional outcome data, poor outcome (modified Rankin scale > 2) was noted in 53.1% (981/1,849) of patients. After adjusting for age, sex, and variables that had a p < 0.05 in univariate analysis or well-known factors for functional outcome, presence of asymptomatic extracranial cerebral atherosclerosis [odd ratio (OR): 1.96, 95% confidence interval (CI): 1.36–2.82, p = 0.001] and less frequent prior stroke statin intake (OR: 0.69, 95% CI: 0.49–0.98, p = 0.038) were associated with poor functional outcome. Conclusion: Our results suggest that presence of non-relevant extracranial cerebral atherosclerosis may affect poor functional outcome and prior stroke statin therapy may be feasible in Korean stroke patients with AF.
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Affiliation(s)
- Tae-Jin Song
- Department of Neurology, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - In-Young Baek
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Ho Geol Woo
- Department of Neurology, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Yong-Jae Kim
- Department of Neurology, Eunpyeong St.Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Younkyung Chang
- Department of Neurology, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sungwook Yu
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Jeong-Min Kim
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Jong-Ho Park
- Department of Neurology, MyongjiHospital, Hanyang University, College of Medicine, Goyang-si, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju-si, South Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Yang-Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
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12
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Effect of direct oral anticoagulant for acute major cerebral artery occlusion in cardioembolic stroke/transient ischemic attack patients with non-valvular atrial fibrillation. J Neurol Sci 2019; 402:162-166. [DOI: 10.1016/j.jns.2019.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 11/23/2022]
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13
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Cardioembolic stroke as consequence of myocardial infarction: case report and concise review. COR ET VASA 2019. [DOI: 10.1016/j.crvasa.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Inaba O, Yamauchi Y, Sekigawa M, Miwa N, Yamaguchi J, Nagata Y, Obayashi T, Miyamoto T, Kamata T, Isobe M, Goya M, Hirao K. Atrial fibrillation type matters: greater infarct volume and worse neurological defects seen in acute cardiogenic cerebral embolism due to persistent or permanent rather than paroxysmal atrial fibrillation. Europace 2019; 20:1591-1597. [PMID: 29244081 DOI: 10.1093/europace/eux346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/27/2017] [Indexed: 11/12/2022] Open
Abstract
Aims Some studies have shown that the type of atrial fibrillation (AF), whether paroxysmal AF (PAF) or persistent or permanent AF (PeAF), affects the incidence of ischaemic stroke. This study sought to determine the relationship between the AF pattern and the severity and brain volume of infarction in an AF population including transient ischaemic attack (TIA) patients. Methods and results This was a retrospective observational study. We studied 161 consecutive patients who were admitted to our stroke care unit with cardiogenic embolism or TIA related to non-valvular AF (age 79 ± 9.5, 78 females, and 87 PAF patients). We evaluated the differences in severity and infarct volume between the types of AF. Additionally, we divided the patients into three groups according to severe stroke (n = 38), TIA (n = 28), and those who were neither (stroke, n = 95) for the assessment of the predictors of severe stroke and TIA. Persistent or permanent atrial fibrillation patients with acute cardiogenic stroke or TIA had worse peak National Institute of Health Stroke Scale (NIHSS) scores [PAF median 4 (range 3-14), PeAF 17 (5.8-25); P < 0.0001] and worse NIHSS scores at discharge [PAF 2.0 (1-7), PeAF 11 (3-22); P < 0.0001]. Their infarct brain volume assessed by computed tomography or magnetic resonance imaging was also larger [PAF 4.4 (1.1-32) mL, PeAF 64 (6.9-170) mL; P < 0.0001]. Multivariate analysis of severe stroke vs. non-severe stroke patients showed that having PeAF was the only independent predictor of severe stroke [odds ratio (OR) 4.27, 95% confidence interval (CI) 1.91-10.2; P = 0.0003]. Comparison of TIA vs. non-TIA patients showed that PeAF (OR 0.120, 95% CI 0.0230-0.444; P = 0.0008) and anticoagulant use (OR 8.24, 95% CI 2.15-40.8; P = 0.0018) were independent predictors of TIA. Conclusion Cardiogenic emboli due to non-valvular PeAF are associated with a worse acute clinical course and greater volume of infarction than those due to PAF.
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Affiliation(s)
- Osamu Inaba
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan.,Department of Cardiology, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan.,Heart Rhythm Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Yasuteru Yamauchi
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Masahiro Sekigawa
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Naoyuki Miwa
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Junji Yamaguchi
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Yasutoshi Nagata
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Toru Obayashi
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Takamichi Miyamoto
- Department of Cardiology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Tomoyuki Kamata
- Department of Neurology, Musashino Red Cross Hospital, Kyonan-cho 1-26-1, Musashino-shi, Tokyo, Japan
| | - Mitsuaki Isobe
- Department of Cardiology, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Masahiko Goya
- Heart Rhythm Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
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15
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Adequate Adherence to Direct Oral Anticoagulant is Associated with Reduced Ischemic Stroke Severity in Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2019; 28:1773-1780. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/02/2018] [Accepted: 09/14/2018] [Indexed: 11/18/2022] Open
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16
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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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17
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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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18
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Hellwig S, Grittner U, Audebert H, Endres M, Haeusler KG. Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace 2019; 20:569-574. [PMID: 28460024 PMCID: PMC5889015 DOI: 10.1093/europace/eux087] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/08/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Several studies showed reduced stroke severity in patients with atrial fibrillation (AF) if the international normalized ratio (INR) was ≥ 2 at stroke onset. There are no respective data for non-vitamin K-dependent oral anticoagulants (NOACs). The aim of this study was to compare the impact of NOAC or phenprocoumon intake on stroke severity. Methods and results In this single-centre observational study, 3669 patients with acute ischaemic stroke were retrospectively analysed regarding AF status and medication immediately before admission. Using multivariable regression, we analysed the association of pre-admission anticoagulation with severe stroke (National Institutes of Health Stroke Scale score ≥ 11) on admission and poor outcome at discharge (modified Rankin scale score > 2). Before the index stroke, 655 patients had known AF and a CHA2DS2-VASc score ≥ 2. While 325 (49.6%) patients were anticoagulated, 159 (24.3%) were prescribed a NOAC and 75 (11.5%) phenprocoumon patients had an INR ≥ 2 on admission. Compared with AF patients without medical stroke prevention, an INR ≥ 2 [OR 0.23 (95% CI 0.10-0.53)] or NOAC intake [OR 0.48 (95% CI 0.27-0.86)] were associated with a lower probability of severe stroke after adjustment for confounders, while an INR < 2 [OR 0.62 (95% CI 0.33-1.16)] was not. Adjusted odds ratios for poor functional outcome at hospital discharge were 0.47 (95% CI 0.27-0.84) for NOAC patients, 0.33 (95% CI 0.17-0.65) for INR ≥ 2 and 0.61 (95% CI 0.32-1.16) for INR < 2. Conclusion NOAC intake before stroke did reduce the probability of severe stroke on hospital admission and poor functional outcome at hospital discharge as similarly demonstrated for phenprocoumon patients with an INR ≥ 2 on admission.
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Affiliation(s)
- Simon Hellwig
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Grittner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Heinrich Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Berlin Institute of Health, Kapelle-Ufer 2, 10117 Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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19
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Impact of pre-admission treatment with non-vitamin K oral anticoagulants on stroke severity in patients with acute ischemic stroke. J Thromb Thrombolysis 2018; 45:529-535. [DOI: 10.1007/s11239-018-1634-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Kato Y, Hayashi T, Tanahashi N, Takao M. The Dose of Direct Oral Anticoagulants and Stroke Severity in Patients with Acute Ischemic Stroke and Nonvalvular Atrial Fibrillation. J Stroke Cerebrovasc Dis 2018; 27:1490-1496. [PMID: 29398536 DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/06/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The severity and the functional outcome of patients with stroke occurring during off-label underdosing of direct-acting oral anticoagulants (DOACs) remain uncertain. METHODS We studied 53 consecutive patients with acute ischemic stroke and nonvalvular atrial fibrillation who were treated with DOACs before the onset of stroke. Thirty patients were treated for primary prevention of stroke and 23 patients were treated for secondary prevention. DOAC treatments were categorized into 3 groups based on the following doses: (1) standard-dose group (n = 17), (2) low-dose group (n = 23), and (3) off-label underdose group (n = 13). RESULTS Age was significantly older in the low-dose group than in the standard-dose group (P = .026). The standard-dose group and the low-dose group showed higher CHA2DS2-VASc scores (median, 4) compared with the off-label underdose group (median, 3). More than half of the patients had a National Institutes of Health Stroke Scale score of less than 8, and many patients had a good outcome (modified Rankin Scale score ≤1). There were no differences in stroke severity and outcome among the 3 groups. The ratio of being discharged home was the highest in the standard-dose group. CONCLUSIONS This study shows that patients who have off-label underdosing of DOACs do not develop more severe stroke and a poorer outcome than those with the recommended dose. Careful attention to recommended doses is required for the full benefits from DOACs.
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Affiliation(s)
- Yuji Kato
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
| | - Takeshi Hayashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Norio Tanahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Masaki Takao
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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21
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Kraft P, Schuhmann MK, Dittmeier M, Fluri F, Kleinschnitz C. Pretreatment with rivaroxaban attenuates stroke severity in rats by a dual antithrombotic and anti-inflammatory mechanism. Thromb Haemost 2017; 115:835-43. [DOI: 10.1160/th15-08-0631] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/23/2015] [Indexed: 01/03/2023]
Abstract
SummaryStroke outcome is more favourable in patients receiving oral anticoagulants compared with non-anticoagulated patients. The reasons for this “stroke-attenuating” property of oral anticoagulants are largely unknown. This study examined whether prestroke anticoagulation with rivaroxaban, a novel direct factor Xa inhibitor, influences stroke severity, thrombin-mediated intracerebral thrombus formation and pro-inflammatory processes in a rat model of brain ischaemia/reperfusion injury. Male Wistar rats were anticoagulated with rivaroxaban and subjected to 90 minutes of transient middle cerebral artery occlusion. Infarct size, functional outcome and the occurrence of intracranial haemorrhage (ICH) were assessed until day 7. Thrombin generation was determined by measuring the amount of thrombin/antithrombin complex. Intracerebral thrombus formation was evaluated by histology and Western blot. CD68-immunoreactivity and the expression of cytokines and adhesion molecules were investigated to assess postischaemic inflammation. The integrity of the blood–brain barrier was analysed using fluorescein isothiocyanate-dextran. Rats pretreated with rivaroxaban developed significantly smaller strokes and less severe functional deficits compared with controls. Although rivaroxaban strongly reduced thrombin-mediated thrombus formation, this was not accompanied by an increased risk of ICH. In addition, rivaroxaban dampened the inflammatory response in the ischaemic brain by downregulating ICAM-1 expression and the activation of CD68+-immune cells. In contrast, rivaroxaban had no effect on the integrity of the blood–brain barrier after stroke. Here, we identified reduced thrombo-inflammation as a major determinant of the stroke-protective property of rivaroxaban in rats. Further studies are needed to assess the therapeutic potential of novel oral anticoagulants in the acute phase after a stroke.
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22
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Bushi D, Stein ES, Golderman V, Feingold E, Gera O, Chapman J, Tanne D. A Linear Temporal Increase in Thrombin Activity and Loss of Its Receptor in Mouse Brain following Ischemic Stroke. Front Neurol 2017; 8:138. [PMID: 28443061 PMCID: PMC5385331 DOI: 10.3389/fneur.2017.00138] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/24/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Brain thrombin activity is increased following acute ischemic stroke and may play a pathogenic role through the protease-activated receptor 1 (PAR1). In order to better assess these factors, we obtained a novel detailed temporal and spatial profile of thrombin activity in a mouse model of permanent middle cerebral artery occlusion (pMCAo). METHODS Thrombin activity was measured by fluorescence spectroscopy on coronal slices taken from the ipsilateral and contralateral hemispheres 2, 5, and 24 h following pMCAo (n = 5, 6, 5 mice, respectively). Its spatial distribution was determined by punch samples taken from the ischemic core and penumbra and further confirmed using an enzyme histochemistry technique (n = 4). Levels of PAR1 were determined using western blot. RESULTS Two hours following pMCAo, thrombin activity in the stroke core was already significantly higher than the contralateral area (11 ± 5 vs. 2 ± 1 mU/ml). At 5 and 24 h, thrombin activity continued to rise linearly (r = 0.998, p = 0.001) and to expand in the ischemic hemisphere beyond the ischemic core reaching deleterious levels of 271 ± 117 and 123 ± 14 mU/ml (mean ± SEM) in the basal ganglia and ischemic cortex, respectively. The peak elevation of thrombin activity in the ischemic core that was confirmed by fluorescence histochemistry was in good correlation with the infarcts areas. PAR1 levels in the ischemic core decreased as stroke progressed and thrombin activity increased. CONCLUSION In conclusion, there is a time- and space-related increase in brain thrombin activity in acute ischemic stroke that is closely related to the progression of brain damage. These results may be useful in the development of therapeutic strategies for ischemic stroke that involve the thrombin-PAR1 pathway in order to prevent secondary thrombin related brain damage.
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Affiliation(s)
- Doron Bushi
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit Stein
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel
| | - Valery Golderman
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ekaterina Feingold
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Gera
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joab Chapman
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Robert and Martha Harden Chair in Mental and Neurological Diseases, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Tanne
- Comprehensive Stroke Center, Department of Neurology, The J. Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel HaShomer, Israel.,Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Foerch C, Schäfer JH, Pfeilschifter W, Bohmann F. [Direct oral anticoagulants and acute stroke : Insights into translational research studies]. DER NERVENARZT 2017; 88:642-651. [PMID: 28188404 DOI: 10.1007/s00115-017-0282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In recent years a considerable number of translational research studies on intracerebral hemorrhage and ischemic stroke have been published, which are characterized by a particular proximity to practical clinical questions. Animal research has provided insights into the pathophysiological processes and therapy effects, which have so far only been insufficiently investigated in clinical studies. This includes the effectiveness of a rapid reversal of anticoagulation in cases of anticoagulation-associated intracerebral hemorrhage and the safety of thrombolytic treatment in ischemic stroke occurring during treatment with anticoagulants. With the approval of the direct oral anticoagulants these problems have become of particular contemporary relevance. Of course, results from experimental translational studies on stroke cannot be directly translated into clinical routine. Nevertheless, these investigations help to understand the underlying processes and mechanisms and provide proof of concept data for new treatment strategies. This review summarizes the most relevant results in this field of research with a particular focus on practical clinical questions.
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Affiliation(s)
- C Foerch
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland.
| | - J H Schäfer
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - W Pfeilschifter
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - F Bohmann
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
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Okumura K, Hagii J, Metoki N, Saito S, Shiroto H, Yasujima M, Tomita H. Prothrombin time on admission in patients with cardioembolic stroke and intracranial hemorrhage occurring during warfarin treatment in the direct oral anticoagulant era. Rinsho Shinkeigaku 2016; 56:309-17. [PMID: 27151227 DOI: 10.5692/clinicalneurol.cn-000857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Warfarin is used worldwide to prevent cardioembolic stroke (CES) in patients with atrial fibrillation even in the era of direct oral anticoagulant (DOAC). We evaluated clinical characteristics of the patients with CES and intracerebral hemorrhage (ICH) occurring during warfarin treatment, focusing on prothrombin time-international normalized ratio (PT-INR) at the occurrence. The consecutive 846 CES patients (78 ± 9 years) and 870 ICH patients (68 ± 13 years) admitted to the Hirosaki Stroke and Rehabilitation Center from April 2011 through March 2015 were studied. The antithrombotic agents administered in CES patients before the onset included antiplatelets in 146 patients (17%), warfarin in 205 (24%), DOAC in 37 (5%), and none in the other 458 (54%). Mean PT-INR within 24 hours after the onset in nonvalvular atrial fibrillation patients with warfarin was 1.34 ± 0.33 (n = 129), and 111 of them (86%) showed PT-INR value below the recommended therapeutic range in Japan. The antithrombotic agents administered in ICH patient included antiplatelets in 87 patients (10%), warfarin in 86 (10%), DOAC in 8 (1%), and none in the other 689 (79%). Mean PT-INR within 24 hours after the onset in patients with warfarin was 2.27 ± 0.62 (n = 65), and 56 of them (86%) showed PT-INR < 2.8. Thus, there is a large population with poor warfarin control complicating CES and that with good warfarin control complicating ICH, indicating limitation of warfarin treatment in the DOAC era.
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Affiliation(s)
- Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine
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