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Chen CH, Shoamanesh A, Colorado P, Saad F, Lemmens R, De Marchis GM, Caso V, Xu L, Heenan L, Masjuan J, Christensen H, Connolly SJ, Khatri P, Mundl H, Hart RG, Smith EE. Hemorrhagic Transformation in Noncardioembolic Acute Ischemic Stroke: MRI Analysis From PACIFIC-STROKE. Stroke 2024; 55:1477-1488. [PMID: 38690666 DOI: 10.1161/strokeaha.123.045204] [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: 09/18/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the phase 2 PACIFIC-STROKE trial (Proper Dosing and Safety of the Oral FXIa Inhibitor BAY 2433334 in Patients Following Acute Noncardioembolic Stroke), asundexian, an oral factor XIa inhibitor, did not increase the risk of hemorrhagic transformation (HT). In this secondary analysis, we aimed to investigate the frequency, types, and risk factors of HT on brain magnetic resonance imaging (MRI). METHODS This was a secondary analysis of the PACIFIC-STROKE trial. Patients with mild-to-moderate acute noncardioembolic ischemic stroke were randomly assigned to asundexian or placebo plus guideline-based antiplatelet therapy. Brain MRIs were required at baseline (≤120 hours after stroke onset) and at 26 weeks or end-of-study. HT was defined using the Heidelberg classification and classified as early HT (identified on baseline MRI) or late HT (new HT by 26 weeks) based on iron-sensitive sequences. Multivariable logistic regression models were used to test factors that are associated with early HT and late HT, respectively. RESULTS Of 1745 patients with adequate baseline brain MRI (mean age, 67 years; mean National Institutes of Health Stroke Scale score, 2.8), early HT at baseline was detected in 497 (28.4%). Most were hemorrhagic infarctions (hemorrhagic infarction type 1: 15.2%; HI2: 12.7%) while a few were parenchymal hematomas (parenchymal hematoma type 1: 0.4%; parenchymal hematoma type 2: 0.2%). Early HT was more frequent with longer symptom onset-to-MRI interval. Male sex, diabetes, higher National Institutes of Health Stroke Scale large (>15 mm) infarct size, cortical involvement by infarct, higher number of acute infarcts, presence of chronic brain infarct, cerebral microbleed, and chronic cortical superficial siderosis were independently associated with early HT in the multivariable logistic regression model. Of 1507 with follow-up MRI, HT was seen in 642 (42.6%) overall, including 361 patients (23.9%) with late HT (new HT: 306; increased grade of baseline HT: 55). Higher National Institutes of Health Stroke Scale, large infarct size, cortical involvement of infarct, and higher number of acute infarcts predicted late HT. CONCLUSIONS About 28% of patients with noncardioembolic stroke had early HT, and 24% had late HT detectable by MRI. Given the high frequency of HT on MRI, more research is needed on how it influences treatment decisions and outcomes.
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Affiliation(s)
- Chih-Hao Chen
- Department of Clinical Neurosciences, University of Calgary, Canada (C.-H.C., F.S., E.E.S.)
- Department of Neurology, National Taiwan University Hospital, Taipei (C.-H.C.)
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology) (A.S., R.G.H.), Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Feryal Saad
- Department of Clinical Neurosciences, University of Calgary, Canada (C.-H.C., F.S., E.E.S.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L.)
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital of Basel and University of Basel, Switzerland (G.M.D.M.)
- Neurology Department and Stroke Center, Kantonsspital St. Gallen, Switzerland (G.M.D.M.)
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Lizhen Xu
- Department of Statistics, Population Health Research Institute, McMaster University, Hamilton, Canada (L.X., L.H.)
| | - Laura Heenan
- Department of Statistics, Population Health Research Institute, McMaster University, Hamilton, Canada (L.X., L.H.)
| | - Jaime Masjuan
- Neurology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain (J.M.)
| | - Hanne Christensen
- Department of Neurology, University Hospital of Copenhagen, Bispebjerg, Denmark (H.C.)
| | - Stuart J Connolly
- Department of Medicine (S.J.C.), Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Sciences, University of Cincinnati, OH (P.K.)
| | - Hardi Mundl
- Bayer AG, TA Thrombosis and Vascular Medicine, Wuppertal, Germany (H.M.)
| | - Robert G Hart
- Department of Medicine (Neurology) (A.S., R.G.H.), Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Canada (C.-H.C., F.S., E.E.S.)
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Castro P, Ferreira J, Malojcic B, Bazadona D, Baracchini C, Pieroni A, Skoloudik D, Azevedo E, Kaps M. Detection of microemboli in patients with acute ischaemic stroke and atrial fibrillation suggests poor functional outcome. Eur Stroke J 2024; 9:409-417. [PMID: 38149620 DOI: 10.1177/23969873231220508] [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] [Indexed: 12/28/2023] Open
Abstract
INTRODUCTION We investigated the burden of microembolic signals (MES) in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF), assessing their impact on functional outcomes. PATIENTS AND METHODS This multicentre international prospective cohort study involved patients with AIS and either a known or newly diagnosed anticoagulant-naïve AF. All centres utilised the same transcranial Doppler machine for 1-h monitoring with bilateral 2 MHz probes within 24 h of symptom onset. Recordings underwent MES analysis by a blinded central reader. The primary objectives were to ascertain the MES proportion and its association with functional outcomes assessed by the modified Rankin scale (mRS) score at 90 days. RESULTS Between September 2019 and May 2021, we enrolled 61 patients, with a median age of 78 years (interquartile range 73-83) and a median stroke severity score of 11 (interquartile range 4-18). MES were observed in 14 patients (23%), predominantly unilateral (12/14, 86%), with a median rate of 6 counts/hour (interquartile range 4-18). MES occurrence was higher post-thrombectomy and among those with elevated brain natriuretic peptide levels (p < 0.05). A worse mRS score of 3-6 was more frequent in patients with MES, occurring in 11/14 (79%), compared to those without MES, 20/47 (43%), with an adjusted odds ratio of 5.04 (95% CI, 1.15-39.4), p = 0.04. CONCLUSIONS Nearly a quarter of patients with AIS and AF exhibited silent microembolization after the index event. Detecting MES within 24 h post-stroke (using transcranial Doppler) could signify a marker of poor functional outcomes. Subsequent trials will assess if very early antithrombotic treatment might enhance outcomes in this highly selective group of cardioembolic stroke patients. (Clinicaltrials.gov ID: NCT06018090).
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Affiliation(s)
- Pedro Castro
- Department of Neurology, Centro Hospitalar Universitário de São João, Faculty of Medicine of University of Porto, Porto, Portugal
| | - J Ferreira
- UnIC@RISE, Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Branko Malojcic
- Department of Neurology, Hospital Centre Zagreb, Zagreb, Croatia
| | - Danira Bazadona
- Department of Neurology, Hospital Centre Zagreb, Zagreb, Croatia
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, University of Padua School of Medicine, Padova. Italy
| | - Alessio Pieroni
- Stroke Unit and Neurosonology Laboratory, University of Padua School of Medicine, Padova. Italy
| | - David Skoloudik
- Center for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar de São João, Faculty of Medicine of University of Porto, Portugal
| | - Manfred Kaps
- Justus-Liebig-University Giessen, Giessen, Germany
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3
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Goeldlin MB, Hakim A, Branca M, Abend S, Kneihsl M, Valenzuela Pinilla W, Fenzl S, Rezny-Kasprzak B, Rohner R, Strbian D, Paciaroni M, Thomalla G, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Bonati L, Aguiar de Sousa D, Sylaja PN, Ntaios G, Koga M, Gdovinova Z, Lemmens R, Bornstein NM, Kelly P, Katan M, Horvath T, Dawson J, Fischer U. Early vs Late Anticoagulation in Minor, Moderate, and Major Ischemic Stroke With Atrial Fibrillation: Post Hoc Analysis of the ELAN Randomized Clinical Trial. JAMA Neurol 2024:2819377. [PMID: 38805207 PMCID: PMC11134281 DOI: 10.1001/jamaneurol.2024.1450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/08/2024] [Indexed: 05/29/2024]
Abstract
Importance Whether infarct size modifies the treatment effect of early vs late direct oral anticoagulant (DOAC) initiation in people with ischemic stroke and atrial fibrillation is unknown. Objective To assess whether infarct size modifies the safety and efficacy of early vs late DOAC initiation. Design, Setting, and Participants Post hoc analysis of participants from the multinational (>100 sites in 15 countries) randomized clinical Early Versus Later Anticoagulation for Stroke With Atrial Fibrillation (ELAN) trial who had (1) acute ischemic stroke, (2) atrial fibrillation, and (3) brain imaging available before randomization. The ELAN trial was conducted between October 2017 and December 2022. Data were analyzed from October to December 2023 for this post hoc analysis. Intervention Early vs late DOAC initiation after ischemic stroke. Early DOAC initiation was within 48 hours for minor or moderate stroke or on days 6 to 7 for major stroke; late DOAC initiation was on days 3 to 4 for minor stroke, days 6 to 7 for moderate stroke, and days 12 to 14 for major stroke. Main Outcomes and Measures The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, extracranial bleeding, systemic embolism, or vascular death within 30 days. The outcome was assessed according to infarct size (minor, moderate, or major) using odds ratios and risk differences between treatment arms. Interrater reliability for infarct size between the core laboratory and local raters was assessed, and whether this modified the estimated treatment effects was also examined. Results A total of 1962 of the original 2013 participants (909 [46.3%] female; median [IQR] age, 77 [70-84] years) were included. The primary outcome occurred in 10 of 371 participants (2.7%) with early DOAC initiation vs 11 of 364 (3.0%) with late DOAC initiation among those with minor stroke (odds ratio [OR], 0.89; 95% CI, 0.38-2.10); in 11 of 388 (2.8%) with early DOAC initiation vs 14 of 392 (3.6%) with late DOAC initiation among those with moderate stroke (OR, 0.80; 95% CI, 0.35-1.74); and in 8 of 219 (3.7%) with early DOAC initiation vs 16 of 228 (7.0%) with late DOAC initiation among those with major stroke (OR, 0.52; 95% CI, 0.21-1.18). The 95% CI for the estimated risk difference of the primary outcome in early anticoagulation was -2.78% to 2.12% for minor stroke, -3.23% to 1.76% for moderate stroke, and -7.49% to 0.81% for major stroke. There was no significant treatment interaction for the primary outcome. For infarct size, interrater reliability was moderate (κ = 0.675; 95% CI, 0.647-0.702) for local vs core laboratory raters and strong (κ = 0.875; 95% CI, 0.855-0.894) between core laboratory raters. Conclusions and Relevance The treatment effect of early DOAC initiation did not differ in people with minor, moderate, or major stroke assessed by brain imaging. Early treatment was not associated with a higher rate of adverse events, especially symptomatic intracranial hemorrhage, for any infarct size, including major stroke. Trial Registration ClinicalTrials.gov Identifier: NCT03148457.
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Affiliation(s)
- Martina B. Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Stefanie Abend
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Kneihsl
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
- 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
| | - Waldo Valenzuela Pinilla
- Support Center for Advanced Neuroimaging, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sabine Fenzl
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beata Rezny-Kasprzak
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roman Rohner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maurizio Paciaroni
- Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Patrik Michel
- Department of Neurology, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - 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
| | | | - Leo Bonati
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal
- Faculty of Medicine, Institute of Anatomy, University of Lisbon, Lisbon, Portugal
| | - P. N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Zuzana Gdovinova
- Department of Neurology, Pavol Jozef Šafárik University, Košice, Slovakia
- Faculty of Medicine, Louis Pasteur University Hospital, Košice, Slovakia
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Kelly
- Stroke Clinical Trials Network Ireland, School of Medicine, University College Dublin and Department of Neurology, Mater University Hospital, Dublin, Ireland
| | - Mira Katan
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, United Kingdom
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
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Ong CJ, Chatzidakis S, Ong JJ, Feske S. Updates in Management of Large Hemispheric Infarct. Semin Neurol 2024. [PMID: 38759959 DOI: 10.1055/s-0044-1787046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.
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Affiliation(s)
- Charlene J Ong
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jimmy J Ong
- Department of Neurology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
- Department of Neurology, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Steven Feske
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024:S0140-6736(24)00642-1. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [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: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Palaiodimou L, Stefanou MI, Katsanos AH, De Marchis GM, Aguiar De Sousa D, Dawson J, Katan M, Karapanayiotides T, Toutouzas K, Paciaroni M, Seiffge DJ, Tsivgoulis G. Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis. Eur Stroke J 2024:23969873241251931. [PMID: 38742375 DOI: 10.1177/23969873241251931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. METHODS We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. RESULTS Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56-0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. CONCLUSIONS Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Gian Marco De Marchis
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Kantonsspital St. Gallen, Switzerland
| | - Diana Aguiar De Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mira Katan
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Rinkel LA, Cramer ON, Özata ZB, Beemsterboer CFP, Guglielmi V, Nio SS, Bouma BJ, Boekholdt SM, Lobé NHJ, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Long-Term Clinical Implications of High-Risk Cardiac Computed Tomography Findings in Patients With Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e033175. [PMID: 38639349 DOI: 10.1161/jaha.123.033175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/26/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cardiac computed tomography (CT) acquired during the initial acute stroke imaging protocol (acute cardiac CT) is increasingly used to screen for cardioembolism, but information on the long-term clinical implications of its findings is lacking. METHODS AND RESULTS We performed a prospective, single-center cohort study in which consecutive patients with ischemic stroke underwent ECG-gated acute cardiac CT and were followed up for 2 years. The primary outcome was functional outcome assessed using the modified Rankin Scale. Secondary outcomes were death and occurrence of major adverse cardiovascular events (composite of recurrent ischemic stroke, myocardial infarction, and cardiovascular death). We compared patients with and without a high-risk structural source of embolism on acute cardiac CT. Of 452 included patients, 55 (12.2%) had a high-risk source of embolism, predominantly cardiac thrombi (38 patients) and signs of endocarditis (8 patients). Follow-up at 2 years was complete for 430 (95.1%) patients. Patients with a high-risk source of embolism had a worse functional outcome (median modified Rankin Scale, 6 [IQR, 2-6] versus 2 [IQR, 1-5]; adjusted common odds ratio, 2.92 [95% CI, 1.62-5.25]), increased mortality rate (52.7% versus 23.7%; adjusted hazard ratio [HR], 3.28 [95% CI, 1.94-5.52]), and major adverse cardiovascular events (38.9% versus 17.5%; adjusted HR, 3.20 [95% CI, 1.80-5.69]). A high-risk source of embolism was not associated with recurrent ischemic stroke (11.1% versus 9.6%; adjusted HR, 1.30 [95% CI, 0.49-3.44]). CONCLUSIONS Structural high-risk sources of embolism on acute cardiac CT in patients with ischemic stroke were associated with poor long-term functional outcome and occurrence of major adverse cardiovascular events but not with recurrent stroke.
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Affiliation(s)
- Leon A Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Olivia N Cramer
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Z Beyda Özata
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Chiel F P Beemsterboer
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Shan Sui Nio
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Nick H J Lobé
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Ludo F M Beenen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Henk A Marquering
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
- Departments of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Charles B L M Majoie
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Adrienne van Randen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - R Nils Planken
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands
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Jumah A, Fu S, Albanna AJ, Agarwal U, Fana M, Choudhury O, Idris A, Elfaham A, Iqbal Z, Schultz L, Latack K, Brady M, Scozzari D, Ramadan AR. Early vs late anticoagulation in acute ischemic stroke with indications outside atrial fibrillation. J Stroke Cerebrovasc Dis 2024; 33:107757. [PMID: 38705498 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107757] [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: 03/07/2024] [Revised: 04/07/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Current literature lacks guidance on the safety of administering anticoagulation in acute ischemic stroke with emergent indications that require anticoagulation other than atrial fibrillation. Therefore, we tend to rely on studies investigating acute ischemic stroke in atrial fibrillation for anticoagulation recommendations. METHODS We retrospectively reviewed data for patients with acute ischemic stroke who had a non-atrial fibrillation emergent indication for anticoagulation (e.g., intra-arterial thrombus, intracardiac thrombus, acute coronary syndrome, acute limb ischemia, deep vein thrombosis and pulmonary embolism) diagnosed within 3 days of acute ischemic stroke. Patients who received anticoagulation ≤ 3 days of stroke onset (Group A) were compared to those who either received it afterwards or did not receive it at all (Group B). RESULTS Out of the 558 patients, only 88 patients met our inclusion criteria. Of the total cohort, 55.7 % patients were males, and basic demographics were similar in both groups except for milder strokes in Group A (national institute of health stroke scale 6 vs. 12.5, p = 0.03). Only 2 patients in Group A and 1 patient in Group B developed intracranial hemorrhage, which was not statistically significant. Group A patients had a lower incidence of both new diagnosis (2 % vs. 34.2 % %, p < 0.001) and propagation of an established venous thromboembolism. They also had a lower rate of any thromboembolic complication (2 % vs. 42 %, p < 0.001). CONCLUSION Early anticoagulation (i.e., ≤ 3 days) in non-atrial fibrillation ischemic stroke patients with an emergent indication may be safe and carry a lower risk of thromboembolic complications than later anticoagulation.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Health, Detroit, MI, USA.
| | - Siyuan Fu
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | | | - Utkarsh Agarwal
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Michael Fana
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Anas Idris
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | | | - Zahid Iqbal
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Lonni Schultz
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Katie Latack
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Megan Brady
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Dawn Scozzari
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
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Kumar M, Beyea S, Hu S, Kamal N. Impact of early MRI in ischemic strokes beyond hyper-acute stage to improve patient outcomes, enable early discharge, and realize cost savings. J Stroke Cerebrovasc Dis 2024; 33:107662. [PMID: 38417567 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107662] [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: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Early in-patient MR Imaging may assist in identifying stroke etiology, facilitating prompt secondary prevention for ischemic strokes (IS), and potentially enhancing patient outcomes. This study explores the impact of early in patient MRI on IS patient outcomes and healthcare resource use beyond the hyper-acute stage. METHODS In this retrospective registry-based study, 771 admitted transient ischemic attack (TIA) and IS patients at Halifax's QEII Health Centre from 2015 to 2019 underwent in-patient MRI. Cohort was categorized into two groups based on MRI timing: early (within 48 h) and late. Logistic regression and Poisson log-linear models, adjusted for age, sex, stroke severity, acute stroke protocol (ASP) activation, thrombolytic, and thrombectomy, were employed to examine in-hospital, discharge, post-discharge, and healthcare resource utilization outcomes. RESULTS Among the cohort, 39.6 % received early in-patient MRI. ASP activation and TIA were associated with a higher likelihood of receiving early MRI. Early MRI was independently associated with a lower rate of symptomatic changes in neurological status during hospitalization (adjusted odds ratio [OR], 0.42; 95 % confidence interval [CI], 0.20-0.88), higher odds of good functional outcomes at discharge (1.55; 1.11-2.16), lower rate of non-home discharge (0.65; 0.46-0.91), shorter length of stay (regression coefficient, 0.93; 95 % CI, 0.89-0.97), and reduced direct cost of hospitalization (0.77; 0.75-0.79). CONCLUSION Early in-patient MRI utilization in IS patients post-hyper-acute stage was independently associated with improved patient outcomes and decreased healthcare resource utilization, underscoring the potential benefits of early MRI during in-patient management of IS. Further research, including randomized controlled trials, is warranted to validate these findings.
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Affiliation(s)
- Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada.
| | - Steven Beyea
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; IWK Health, Halifax, Canada
| | - Sherry Hu
- Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada; Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
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10
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Yang J, Jing J, Chen S, Liu X, Wang J, Pan C, Tang Z. Reversal and resumption of anticoagulants in patients with anticoagulant-associated intracerebral hemorrhage. Eur J Med Res 2024; 29:252. [PMID: 38659079 PMCID: PMC11044346 DOI: 10.1186/s40001-024-01816-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
The use of anticoagulants has become more frequent due to the progressive aging population and increased thromboembolic events. Consequently, the proportion of anticoagulant-associated intracerebral hemorrhage (AAICH) in stroke patients is gradually increasing. Compared with intracerebral hemorrhage (ICH) patients without coagulopathy, patients with AAICH may have larger hematomas, worse prognoses, and higher mortality. Given the need for anticoagulant reversal and resumption, the management of AAICH differs from that of conventional medical or surgical treatments for ICH, and it is more specific. Understanding the pharmacology of anticoagulants and identifying agents that can reverse their effects in the early stages are crucial for treating life-threatening AAICH. When patients transition beyond the acute phase and their vital signs stabilize, it is important to consider resuming anticoagulants at the right time to prevent the occurrence of further thromboembolism. However, the timing and strategy for reversing and resuming anticoagulants are still in a dilemma. Herein, we summarize the important clinical studies, reviews, and related guidelines published in the past few years that focus on the reversal and resumption of anticoagulants in AAICH patients to help implement decisive diagnosis and treatment strategies in the clinical setting.
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Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiahui Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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11
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Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. Lancet Neurol 2024; 23:404-417. [PMID: 38508836 DOI: 10.1016/s1474-4422(24)00037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland.
| | - Virginia Cancelloni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lorenz Räber
- Department of Cardiology, Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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12
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Lee M, Lee BC, Yu KH, Oh MS, Kim BJ, Kim JY, Kang J, Lee KJ, Kim DY, Park JM, Kang K, Park TH, Lee KB, Hong KS, Park HK, Cho YJ, Kim DE, Lee SJ, Kim JG, Lee J, Cha JK, Kim DH, Kim JT, Choi KH, Choi JC, Sohn SI, Hong JH, Lee SH, Kim C, Shin DI, Yum KS, Lee J, Lee JS, Gorelick PB, Bae HJ. Secular Trends in Outcomes and Impact of Novel Oral Anticoagulants in Atrial Fibrillation-Related Acute Ischemic Stroke. Stroke 2024; 55:625-633. [PMID: 38328909 DOI: 10.1161/strokeaha.123.044487] [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: 07/12/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) are currently recommended for the secondary prevention of stroke in patients with acute ischemic stroke (AIS) accompanied by atrial fibrillation (AF). However, the impact of NOACs on clinical outcomes in real-world practice remains ambiguous. This study analyzes the trend of clinical events in patients with AF-related AIS and determines how much the introduction of NOACs has mediated this trend. METHODS We identified patients with AIS and AF between January 2011 and December 2019 using a multicenter stroke registry. Annual rates of NOAC prescriptions and clinical events within 1 year were evaluated. The primary outcome was a composite of recurrent stroke, myocardial infarction, and all-cause mortality. To assess the mediation effect of NOACs on the relationship between the calendar year and these outcomes, we used natural effect models and conducted exposure-mediator, exposure-outcome, and mediator-outcome analyses using multivariable regression models or accelerated failure time models, adjusting for potential confounders. RESULTS Among the 12 977 patients with AF-related AIS, 12 500 (average age: 74.4 years; 51.3% male) were analyzed after excluding cases of valvular AF. Between 2011 and 2019, there was a significant decrease in the 1-year incidence of the primary composite outcome from 28.3% to 21.7%, while the NOAC prescription rate increased from 0% to 75.6%. A 1-year increase in the calendar year was independently associated with delayed occurrence of the primary outcome (adjusted time ratio, 1.10 [95% CI, 1.07-1.14]) and increased NOAC prescription (adjusted odds ratio, 2.20 [95% CI, 2.14-2.27]). Increased NOAC prescription was associated with delayed occurrence of the primary outcome (adjusted time ratio, 3.82 [95% CI, 3.17 to 4.61]). Upon controlling for NOAC prescription (mediator), the calendar year no longer influenced the primary outcome (adjusted time ratio, 0.97 [95% CI, 0.94-1.00]). This suggests that NOAC prescription mediates the association between the calendar year and the primary outcome. CONCLUSIONS Our study highlights a temporal reduction in major clinical events or death in Korean patients with AF-related AIS, mediated by increased NOAC prescription, emphasizing NOAC use in this population.
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Affiliation(s)
- Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea (K.-J.L.)
| | - Do Yeon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jong-Moo Park
- Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea (J.-M.P.)
| | - Kyusik Kang
- Nowon Elji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea (K.K.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Republic of Korea (T.H.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital Seoul, Republic of Korea (K.B.L.)
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, Republic of Korea (D.-E.K., S.J.L.)
| | - Soo Joo Lee
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, Republic of Korea (D.-E.K., S.J.L.)
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, Republic of Korea (J.G.K.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Republic of Korea (Jun Lee)
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea (J.-K.C., D.-H.K.)
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea (J.-K.C., D.-H.K.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K., K.-H.C.)
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K., K.-H.C.)
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Republic of Korea (J.C.C.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea (S.-I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea (S.-I.S., J.-H.H.)
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Republic of Korea (S.-H.L., C.K.)
| | - Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Republic of Korea (S.-H.L., C.K.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea (D.-I.S., K.S.Y.)
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea (D.-I.S., K.S.Y.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.S.L.)
| | - Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.B.G.)
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
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Philippe D, Bernard A, Ricolfi F, Béjot Y, Duloquin G, Comby PO, Guenancia C. Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke. Diagn Interv Imaging 2024:S2211-5684(24)00047-0. [PMID: 38431431 DOI: 10.1016/j.diii.2024.02.012] [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: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.
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Affiliation(s)
- Diane Philippe
- Department of Radiology, University Hospital, 21709 Dijon, France
| | | | - Frédéric Ricolfi
- Department of Radiology, University Hospital, 21709 Dijon, France
| | - Yannick Béjot
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Gauthier Duloquin
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Pierre-Olivier Comby
- Department of Radiology, University Hospital, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Charles Guenancia
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Cardiology, University Hospital, 21709 Dijon, France.
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14
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Ansari U, Brachmann J, Lewalter T, Zeymer U, Sievert H, Ledwoch J, Geist V, Hochadel M, Schneider S, Senges J, Akin I, Fastner C. LAA occlusion is effective and safe in very high-risk atrial fibrillation patients with prior stroke: results from the multicentre German LAARGE registry. Clin Res Cardiol 2024:10.1007/s00392-024-02376-8. [PMID: 38294498 DOI: 10.1007/s00392-024-02376-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Interventional left atrial appendage occlusion (LAAO) mitigates the risk of thromboembolic events in nonvalvular atrial fibrillation (AF) patients with contraindication for long-term oral anticoagulation (OAC). Patients with prior stroke have a relevantly increased risk of recurrent stroke, so the effectiveness of LAAO could be reduced in this specific very high-risk patient group. AIM This sub-study of the LAARGE registry investigates the effectiveness and safety of LAAO for secondary prevention in nonvalvular AF patients with a history of stroke. METHODS LAARGE is a prospective, non-randomised registry on the clinical reality of LAAO. The current sub-study employs data from index procedure and 1-year follow-up. Effectiveness and safety were assessed by documentation of all-cause mortality, non-fatal thromboembolism, procedure-related complications, and bleeding events. RESULTS A total of 638 patients were consecutively included from 38 hospitals in Germany and divided into two groups: 137 patients with a history of stroke (21.5%) and 501 patients without. Successful implantation was consistent between both groups (98.5% vs. 97.4%, p = NS), while peri-procedural MACCE and other complications were rare (0% vs. 0.6% and 4.4% vs. 4.0%, respectively; each p = NS). Kaplan-Meier estimate showed no significant difference in primary effectiveness outcome measure (freedom from all-cause death or non-fatal stroke) between both groups at follow-up (87.8% vs. 87.7%, p = NS). The incidence of transient ischemic attack or systemic embolism at follow-up was low (0% vs. 0.5% and 0.9% vs. 0%, respectively; each p = NS). Severe bleeding events after hospital discharge were rare (0% vs. 0.7%, p = NS). CONCLUSIONS Patients with prior stroke demonstrated similar effectiveness and safety profile for LAAO as compared to patients without prior stroke. LAAO could serve as a feasible alternative to OAC for secondary stroke prevention in this selected group of nonvalvular AF patients. CLINICALTRIALS GOV IDENTIFIER NCT02230748.
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Affiliation(s)
- Uzair Ansari
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Johannes Brachmann
- Department of Cardiology, Angiology, and Pneumology, Second Medical Clinic, Coburg Hospital, Coburg, Germany
- University of Split School of Medicine, Split, Croatia
| | - Thorsten Lewalter
- Department of Medicine, Cardiology, and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Uwe Zeymer
- Medizinische Klinik B, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt am Main, Germany
| | - Jakob Ledwoch
- Isar Herz Zentrum München, ISAR Klinikum, Munich, Germany
- Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, München Klinik Neuperlach, Munich, Germany
| | - Volker Geist
- Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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15
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Matsuzono K, Mashiko T, Koide R, Yoshizumi H, Fujimoto S. Comparison of Prognosis and Cognitive Function of Holistic Neurological Disease: Tochigi Neurological Disease Cohort Study. J Alzheimers Dis 2024; 98:275-285. [PMID: 38393916 DOI: 10.3233/jad-231390] [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] [Indexed: 02/25/2024]
Abstract
Background While many studies focus on the prognosis of individual neurological diseases, very few comprehensively compare and analyze real-world data of these diseases. Objective To address this gap in knowledge, in this study, we comprehensively analyzed the real-life data of patients with neurological diseases. Methods We prospectively enrolled patients with neurological diseases at three hospitals from December 1, 2016 to September 30, 2020. Neurological diseases were classified into nine groups: Dementia, Cerebrovascular disease, Parkinson's and related, Functional, Spinocerebellar degeneration, Neuroimmune, Epilepsy, Muscle dystrophy disease, and Hypertension. Patients were followed up for three years, and their prognosis and evaluation of their cognitive function served as the endpoint. Results A total of 426 patients were finally enrolled. Both mortality and cognitive function differed among the neurological disease categories. After 3 years, mortality was highest in the Dementia (25.5%), Parkinson's and related (21.6%), and Spinocerebellar degeneration (35.3%) groups while the cognitive function of patients in these three groups was significantly lowest. Conclusions When the neurological diseases were holistically observed, both mortality and cognitive function of the Dementia, Parkinson's and related, and Spinocerebellar degeneration groups were significantly worse than the remaining diseases.
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Affiliation(s)
- Kosuke Matsuzono
- Department of Medicine, Division of Neurology, Jichi Medical University, Tochigi, Japan
- Department of Medicine, Kamitsuga General Hospital, Tochigi, Japan
- Department of Internal Medicine, Imai Hospital, Tochigi, Japan
| | - Takafumi Mashiko
- Department of Medicine, Division of Neurology, Jichi Medical University, Tochigi, Japan
| | - Reiji Koide
- Department of Medicine, Division of Neurology, Jichi Medical University, Tochigi, Japan
| | | | - Shigeru Fujimoto
- Department of Medicine, Division of Neurology, Jichi Medical University, Tochigi, Japan
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16
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [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: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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17
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Wu X, Xu Y, Wei M, Li M, Lei X, Yuan H, Guo J, Zhang Q, Zhang X, Sun M, Fan T, Luo G. Oral anticoagulants status after acute ischemic stroke and prognosis in patients with atrial fibrillation. J Stroke Cerebrovasc Dis 2024; 33:107452. [PMID: 37931484 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107452] [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: 07/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES To investigate the oral anticoagulants (OACs) use after acute ischemic stroke (AIS) and prognosis of patients with atrial fibrillation (AF). METHODS This was a real-world follow-up research of AIS patients with AF admitted to 5 hospitals in northwestern China. We visited these individuals every 6 months to check the type, dosage of OACs, and to record IS recurrence, bleeding, and death events and modified Rankin Scale (mRS) scores until December 2022. When one of the following occurring first was endpoint: IS recurrence, death or study end. Patients were divided into continuous anticoagulation group and non-continuous anticoagulation group based on whether they continued to take OACs from the moment they were discharged until the endpoint. We further analyzed the association between anticoagulation persistence and outcomes. RESULTS Among all 250 patients with OACs indication, 147 patients (58.8 %) received OACs at discharge. Only 37.9 % of patients (39/103) started OACs after discharge. Of the 147 patients treated with OACs, 21.8 % (32/147) discontinued anticoagulation after discharge. 239 of the 250 patients had completed the median 40-month follow-up with 91 patients in continuous anticoagulation group and 148 patients in non-continuous anticoagulation group. In the multivariate COX regression, non-continuous anticoagulation was an independent risk factor for poor prognosis (mRS>2) in AIS patients with AF (1.452[1.011, 2.086], p = 0.043). CONCLUSIONS This study revealed an upward trend in the use rate of OACs, but low OACs rates that meet guideline-based criteria and low anticoagulation persistence in AF patients after AIS in the northwestern China. Discontinuous anticoagulation was associated with an increased risk of poor prognosis in these patients.
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Affiliation(s)
- Xiaoyu Wu
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China; Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Yue Xu
- Department of Neurology, Ninth hospital of Xi'an, No. 151 East Section of South Second Ring Road, Xi'an 710054, China
| | - Meng Wei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Mengmeng Li
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Xiangyu Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Huijie Yuan
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Jing Guo
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No.55 Xingshansi West Street, Xi'an 710061, China
| | - Qiang Zhang
- Department of Neurology, Shaanxi Provincial People's Hospital, No. 256 Youyi West Road, Xi'an 710068, China
| | - Xiao Zhang
- Department of Neurology, Xijing Hospital of Air Force Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Man Sun
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an 710004, China
| | - Tong Fan
- Department of Neurology, Xi'an Gaoxin Hospital, No. 16 Tuanjie South Road, Xi'an 710075, China
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China.
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18
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Kessler A, Kolben Y, Puris G, Ellis M, Alperin M, Simovich V, Lerman Shivek H, Muszkat M, Maaravi Y, Biton Y. Direct Oral Anticoagulants in Special Patient Populations. J Clin Med 2023; 13:216. [PMID: 38202223 PMCID: PMC10779957 DOI: 10.3390/jcm13010216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.
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Affiliation(s)
- Asa Kessler
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Yotam Kolben
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Gal Puris
- Faculty of Medicine, Institute for Research in Military Medicine, Hebrew University of Jerusalem, Israel Defense Force Medical Corps, Jerusalem 9112002, Israel;
| | - Martin Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba 4428164, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mordechai Alperin
- Department of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Clalit Health Services, Haifa and Western Galilee District, Tel Aviv 6209804, Israel
| | | | - Hila Lerman Shivek
- Hospital Pharmacy Department, Hospitals Division, Clalit Health Services, Tel Aviv 6209804, Israel;
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Mt. Scopus, Jerusalem 9112002, Israel;
| | - Yoram Maaravi
- The Jerusalem Institute of Aging Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel;
- Department of Geriatrics and Rehabilitation and the Center for Palliative Care, Hadassah Medical Center, Jerusalem 9371125, Israel
| | - Yitschak Biton
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
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19
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [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: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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20
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Suomalainen OP, Martinez-Majander N, Broman J, Mannismäki L, Aro A, Curtze S, Pakarinen S, Lehto M, Putaala J. Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis. J Clin Med 2023; 13:30. [PMID: 38202037 PMCID: PMC10779359 DOI: 10.3390/jcm13010030] [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: 11/01/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.
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Affiliation(s)
- Olli Pekka Suomalainen
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Nicolas Martinez-Majander
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Jenna Broman
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Laura Mannismäki
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Aapo Aro
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Sami Curtze
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Sami Pakarinen
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Mika Lehto
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Jukka Putaala
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
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21
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Worthmann H, Ernst J, Grosse GM. [What is confirmed in the treatment of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1143-1153. [PMID: 37947809 DOI: 10.1007/s00108-023-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke is one of the leading causes of death worldwide and the most frequent cause of permanent disability in adulthood. The acute treatment of stroke is time-critical and, according to the time is brain principle, it is important to determine as soon as possible whether recanalization treatment that can save the penumbra is possible. Intravenous thrombolysis (IVT) and, if a large vessel occlusion is identified, endovascular treatment (EVT) possibly in combination with IVT, are recommended. Further treatment in a stroke unit is another important component of acute stroke treatment. The best secondary preventive treatment must already be initiated in the acute phase. The cause of stroke guides making decisions on the ideal secondary preventive strategy. The most important etiologies of stroke are cardiac embolism, atherosclerotic macroangiopathy and cerebral microangiopathy (small vessel disease). Less frequent causes are dissections of arteries supplying the brain or vasculitis. In up to 20-30% of all cases, however, no clear etiology can be determined despite intensive investigation of the cause. This means corresponding uncertainty in the optimal secondary prevention that consists in particular of an anticoagulant medication adapted to the etiology, treatment of cardiovascular risk factors and if necessary surgical or interventional desobliterative procedures. This article describes the diagnostic procedure and the evidence-based treatment of ischemic stroke.
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Affiliation(s)
- Hans Worthmann
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland.
| | - Johanna Ernst
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
| | - Gerrit M Grosse
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
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22
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Schmidbauer M, Wischmann J, Dimitriadis K, Kellert L. [Secondary prophylaxis of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1171-1183. [PMID: 37947810 DOI: 10.1007/s00108-023-01615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.
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Affiliation(s)
- Moritz Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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23
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Paciaroni M, Caso V, Romoli M, Becattini C, Salerno A, Rapillo C, Simonnet F, Strambo D, Canavero I, Zedde M, Pascarella R, Sohn SI, Sacco S, Ornello R, Barlinn K, Schoene D, Rahmig J, Mosconi MG, Leone De Magistris I, Alberti A, Venti M, Silvestrelli G, Ciccone A, Padroni M, Laudisi M, Zini A, Gentile L, Kargiotis O, Tsivgoulis G, Tassi R, Guideri F, Acampa M, Masotti L, Grifoni E, Rocco A, Diomedi M, Karapanayiotides T, Engelter ST, Polymeris AA, Zietz A, Bandini F, Caliandro P, Reale G, Moci M, Zauli A, Cappellari M, Emiliani A, Gasparro A, Terruso V, Mannino M, Giorli E, Toni D, Andrighetti M, Falcou A, Palaiodimou L, Ntaios G, Sagris D, Karagkiozi E, Adamou A, Halvatsiotis P, Flomin Y, Scoditti U, Genovese A, Popovic N, Pantoni L, Mele F, Molitierno N, Lochner P, Pezzini A, Del Sette M, Sassos D, Giannopoulos S, Kosmidou M, Ntais E, Lotti EM, Mastrangelo V, Chiti A, Naldi A, Vanacker P, Ferrante M, Volodina V, Mancuso M, Giannini N, Baldini M, Vadikolias K, Kitmeridou S, Saggese CE, Tassinari T, Saia V, Michel P. Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study. Eur Stroke J 2023; 8:1030-1040. [PMID: 37452632 PMCID: PMC10683741 DOI: 10.1177/23969873231186863] [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: 05/19/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group). PATIENTS AND METHODS For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days. RESULTS Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05-3.18; p = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84-3.47; p = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95-3.73; p = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95-2.85; p = 0.07). CONCLUSION Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.
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Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alexander Salerno
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Costanza Rapillo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Fanny Simonnet
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Isabella Canavero
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico “Carlo Besta,” Milano, Italy
| | - Marialuisa Zedde
- Neurology Unit, AUSL - IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy
| | - Marina Padroni
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Michele Laudisi
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Luana Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | | | | | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | | | - 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
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabio Bandini
- Department of Neurology, ASL 3 Genovese, Genova, Italy
| | - Pietro Caliandro
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Reale
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Moci
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aurelia Zauli
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Emiliani
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | | | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant’Andrea Hospital, La Spezia, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marco Andrighetti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Anne Falcou
- Stroke Unit – Emergency Department, Policlinico Umberto I, Rome, Italy
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anastasia Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Panagiotis Halvatsiotis
- Second Department of Internal Medicine-Propaedeutic and Diabetes Center, Medical School, University General Hospital “Attikon,” National and Kapodistrian University of Athens, Greece
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit MC ‘Universal Clinic “Oberig” Kyiv, Kyiv, Ukraine
| | - Umberto Scoditti
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Antonio Genovese
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Nemanja Popovic
- Clinic of Neurology, University Clinical Center of Vòsvodina, University of Novi Sad, Novi Sad, Serbia
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Francesco Mele
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Nicola Molitierno
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University, Medical Center, Homburg, Germany
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | | | - Davide Sassos
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Kosmidou
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Evangelos Ntais
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | | | | | | | - Andrea Naldi
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Peter Vanacker
- NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Groeninge Hospital, Kortrijk, Belgium
| | - Mario Ferrante
- Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital # 1, Novosibirsk (Russia) at the Novosibirsk State Medical University, Novosibirsk, Russia
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Nicola Giannini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Marco Baldini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Kostantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Tiziana Tassinari
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Valentina Saia
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Patrik Michel
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
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Markus HS. December highlights. Int J Stroke 2023; 18:1148-1150. [PMID: 37997946 DOI: 10.1177/17474930231212536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
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25
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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [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: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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26
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Huang J, Wu B, Qin P, Cheng Y, Zhang Z, Chen Y. Research on atrial fibrillation mechanisms and prediction of therapeutic prospects: focus on the autonomic nervous system upstream pathways. Front Cardiovasc Med 2023; 10:1270452. [PMID: 38028487 PMCID: PMC10663310 DOI: 10.3389/fcvm.2023.1270452] [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: 07/31/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Atrial fibrillation (AF) is the most common clinical arrhythmia disorder. It can easily lead to complications such as thromboembolism, palpitations, dizziness, angina, heart failure, and stroke. The disability and mortality rates associated with AF are extremely high, significantly affecting the quality of life and work of patients. With the deepening of research into the brain-heart connection, the link between AF and stroke has become increasingly evident. AF is now categorized as either Known Atrial Fibrillation (KAF) or Atrial Fibrillation Detected After Stroke (AFDAS), with stroke as the baseline. This article, through a literature review, briefly summarizes the current pathogenesis of KAF and AFDAS, as well as the status of their clinical pharmacological and non-pharmacological treatments. It has been found that the existing treatments for KAF and AFDAS have limited efficacy and are often associated with significant adverse reactions and a risk of recurrence. Moreover, most drugs and treatment methods tend to focus on a single mechanism pathway. For example, drugs targeting ion channels primarily modulate ion channels and have relatively limited impact on other pathways. This limitation underscores the need to break away from the "one disease, one target, one drug/measurement" dogma for the development of innovative treatments, promoting both drug and non-drug therapies and significantly improving the quality of clinical treatment. With the increasing refinement of the overall mechanisms of KAF and AFDAS, a deeper exploration of physiological pathology, and comprehensive research on the brain-heart relationship, it is imperative to shift from long-term symptom management to more precise and optimized treatment methods that are effective for almost all patients. We anticipate that drugs or non-drug therapies targeting the central nervous system and upstream pathways can guide the simultaneous treatment of multiple downstream pathways in AF, thereby becoming a new breakthrough in AF treatment research.
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Affiliation(s)
- Jingjie Huang
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Bangqi Wu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Peng Qin
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yupei Cheng
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ziyi Zhang
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yameng Chen
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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27
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Jiang M, Wang C, Zhang Y. Comparison of early and delayed anticoagulation therapy after ischemic stroke in patients with atrial fibrillation: a systematic review and meta-analysis. J Thromb Thrombolysis 2023; 56:603-613. [PMID: 37505339 DOI: 10.1007/s11239-023-02872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
The optimal initiation timing of oral anticoagulants (OACs) remains controversial in patients with atrial fibrillation (AF)-related acute ischemic stroke (AIS). The aim of this study is to compare the efficacy and safety of early OACs initiation with that of the delayed initiation for AIS and AF.We searched systematically the following mainstream databases: PubMed, Embase, and Web of Science from the inception to July 2023 for studies that compared the early initiation with the delayed initiation of OACs for AF-related AIS patients. Outcome measures were the incidence of hemorrhagic events, ischemic events, and combined outcomes, as well as all-cause mortality.There were 12 eligible articles included (10 cohort studies and 2 RCT), involving 11421 patients (5690 patients in the early-initiation group and 5731 in the delayed-initiation group). Meta-analysis revealed that patients receiving OACs at the early stage of stroke had a lower incidence of ischemic events (OR: 0.68; 95% CI: 0.55,0.84; p = 0.0003) and combined outcomes (OR=0.74, 95% CI (0.57,0.95), p=0.02). No significant differences were identified in the incidence of hemorrhagic events (p = 0.26) and all-cause mortality ( p = 0.20) between the groups.Early initiation of anticoagulation therapy would be preferable in lowering the incidence of ischemic events and combined outcomes in AIS patients with AF. It is safe compared to the delayed-initiation strategy. However, the conclusion of this study needs to be further validated by more well-designed RCTs.
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Affiliation(s)
- Mengjin Jiang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China.
| | - Congyao Wang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China
| | - Yaodong Zhang
- Department of Pharmacy, The First people's Hospital of Xiaoshan District, No. 199 Shixin South Road, Hangzhou, Zhejiang, 311200, China
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28
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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29
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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30
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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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31
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Hindsholm MF, Damgaard D, Gurol ME, Gaist D, Simonsen CZ. Management and Prognosis of Acute Stroke in Atrial Fibrillation. J Clin Med 2023; 12:5752. [PMID: 37685819 PMCID: PMC10489015 DOI: 10.3390/jcm12175752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting.
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Affiliation(s)
- Mette F. Hindsholm
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
| | - M. Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark;
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
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32
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Tirumandyam G, Krishna Mohan GV, Addi Palle LR, Reyaz I, Haider S, Haseeb MD, Saleem F. Early Versus Delayed Oral Anticoagulation in Patients With Acute Ischemic Stroke Due to Atrial Fibrillation: A Meta-Analysis. Cureus 2023; 15:e40801. [PMID: 37485143 PMCID: PMC10362836 DOI: 10.7759/cureus.40801] [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] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
The aim of this study was to compare the safety and efficacy of early oral anticoagulation with delayed anticoagulant therapy in patients who have had a recent stroke and have atrial fibrillation (AF). This meta-analysis was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) statement. The literature search was independently performed by two authors. We searched PubMed and Scopus using search strings that included the following terms: "stroke," "atrial fibrillation," "oral anticoagulants," "recurrent stroke," and "intracerebral hemorrhage." Our search spanned from the inception of databases to May 25, 2023. The primary outcome assessed in this study was the composite efficacy outcome (as defined by individual studies). Recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), and death from any cause were assessed as secondary outcomes. For safety analysis, bleeding events were compared between the two study groups. We included five articles in this meta-analysis, comprising a total of 7958 patients (including 3793 in the early treatment group and 4165 in the delayed treatment group). Pooled analysis showed that the risk of composite efficacy outcome (RR: 0.69, 95% CI: 0.51-0.93, p-value: 0.01) and recurrent ischemic stroke (RR: 0.71, 95% CI: 0.53-0.94, p-value: 0.02) were lower in the early treatment group. However, no significant differences were observed between the two groups in terms of all-cause mortality, intracranial hemorrhage, or bleeding events. In light of the findings, healthcare professionals should carefully evaluate the risks and benefits of early versus delayed DOAC treatment in individual patients, considering factors such as stroke severity, bleeding risk, and patient preferences.
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Affiliation(s)
- Gayathri Tirumandyam
- Internal Medicine, Siddhartha Medical College, Dr Nandamuri Taraka Rama Rao (NTR) University of Health Sciences, Tirupathi, IND
| | | | | | - Ibrahim Reyaz
- Internal Medicine, Christian Medical College and Hospital, Ludhiana, IND
| | - Salar Haider
- Medicine, King Edwards Medical University, Islamabad, PAK
| | | | - Faraz Saleem
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Akhtar Saeed Medical and Dental College, Lahore, PAK
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