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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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Zhang JC, Bhat A. Atrial Cardiopathy: Redefining Stroke Risk Beyond Atrial Fibrillation. Am J Cardiol 2023; 201:177-184. [PMID: 37385172 DOI: 10.1016/j.amjcard.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
Atrial fibrillation (AF) and ischemic stroke are dual epidemics in society, both associated with poor clinical outcomes, patient disability, and significant healthcare expenditure. The conditions are interrelated and share complex causal pathways. Risk stratification algorithms such as the CHADS2 and CHA2DS2-VASc score offer predictive value in stroke and systemic embolism risk in the AF population, however, have limitations. Recent evidence suggests that an intrinsically prothrombotic atrial substrate may precede and promote AF and lead to thromboembolic events independent of the arrhythmia, allowing for a window of intervention before arrhythmia detection and development of ischemic stroke. Initial work has found incremental value in addition of parameters of atrial cardiopathy to traditional stroke risk stratification algorithms, however, requires evaluation with dedicated prospective randomized studies before use in real-world clinical practice. In this narrative review, we explore current evidence and literature on the use of measures of atrial cardiopathy in stroke risk stratification and management.
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Affiliation(s)
- Jessica Chu Zhang
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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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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Yaghi S, Henninger N, Giles JA, Leon Guerrero C, Mistry E, Liberman AL, Asad D, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Furie KL, Keyrouz SG, Nouh A, de Havenon A, Khan M, Smith EE, Gurol ME. Ischaemic stroke on anticoagulation therapy and early recurrence in acute cardioembolic stroke: the IAC study. J Neurol Neurosurg Psychiatry 2021; 92:1062-1067. [PMID: 33903185 PMCID: PMC8448925 DOI: 10.1136/jnnp-2021-326166] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/09/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE A subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH). METHODS We included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve). RESULTS Among 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641). CONCLUSION AF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.
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Affiliation(s)
- Shadi Yaghi
- Dpeartment of Neurology, Brown University, Providence, Rhode Island, USA
| | - Nils Henninger
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Psychiatry, University of Massachusetts, Worcester, Massachusetts, USA
| | - James A Giles
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Christopher Leon Guerrero
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Eva Mistry
- Neurology, Vanderbilt University, Nashville, Tennessee, USA
| | - Ava L Liberman
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Daniyal Asad
- Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Angela Liu
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Muhammad Nagy
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ashutosh Kaushal
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Idrees Azher
- Neurology, Vanderbilt University, Nashville, Tennessee, USA.,Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Brian Mac Grory
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Hiba Fakhri
- Neurology, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | - Heather Martin
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA
| | - Jose Tan
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA
| | | | - Charles Esenwa
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Natalie Cheng
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | | | - Iman Moeini-Naghani
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Mithilesh Siddu
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Erica Scher
- Neurology, NYU Langone Health, New York, New York, USA
| | | | - Karen L Furie
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Salah G Keyrouz
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Amre Nouh
- Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Adam de Havenon
- Neurology, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
| | - Muhib Khan
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA.,Neurology, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Neurology, Harvard Medical School, Boston, Massachusetts, USA
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