Background: In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. Methods: This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. Results: After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA 2 DS 2 -VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0–1.3] for each point increase; P =0.05) and hypertension (OR, 2.3 [95% CI, 1.0–5.1]; P =0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0–1.2] for each year increase; P =0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4–14.2]; P =0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4–5.5]; P =0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8–1.7]). Conclusions: Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding.

Cerebral stroke remains the leading cause of death and disability worldwide as well as in Ukraine. After a cerebral stroke, there is an increased risk of a new cerebral stroke (9‒15 % within 1 year), and about a quarter of all cerebral stroke are recurrent. Up to 80 % of recurrent cerebral stroke can be avoided through lifestyle modifications (healthy diet, sufficient amount of physical activity, normalization of body weight, cessation of smoking and alcohol abuse) and control of chronic diseases such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. The key to effective secondary prevention is determining the etiology of cerebral stroke, which requires a primary examination in all cases and a number of additional tests as needed. The most common causes of ischemic cerebral stroke are cardiogenic embolism, atherosclerosis of the large cerebral arteries (macroangiopathy), and brain small vessels disease (microangiopathy), but approximately 1/3 of cerebral stroke have other, rear, determined cause or the cause remains unknown despite the appropriate workup (cryptogenic cerebral stroke). In the review, we discuss modern approaches to ischemic cerebral stroke classification and determination of their etiology, from the most prevalent to the rarest causes. A careful search for the cause of cerebral stroke is particularly important in young patients (aged 18 to 50 years) with a high life expectancy. We have reviewed in detail the possibilities of screening for subclinical atrial fibrillation by long-term cardiac monitoring with implantable devices and the diagnosis of monogenetic causes of cerebral stroke, with a particular focus on Fabry disease, for which there is an effective treatment.

Introduction: Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. Patients and methods: We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). Results: During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01–1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48–3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02–2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19–3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01–1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06–4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23–4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35–2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45–2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06–3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05–2.74]). Discussion: Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. Conclusion: Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.

Инсульт остается ведущей причиной смертности и приобретенной инвалидности среди людей старшего возраста во всем мире. К числу факторов, оказывающих наибольшее влияние на результаты лечения инсульта в стационаре, относятся клинико-демографические особенности больного, ресурсы больницы и организация лечебного процесса в отделении, где находится пациент. При остром инсульте качественная медицинская помощь способствует снижению риска смерти и зависимости от посторонней помощи. Хотя оптимальная модель организации помощи в стационаре пока не определена, накоплен большой объем доказательств эффективности инсультного блока (Stroke Unit), где структура и процессы имеют существенные особенности по сравнению с общей палатой. Наибольшие преимущества при лечении инсульта в стационаре обеспечивают комплексные инсультные блоки, позволяющие сочетать решение острых медицинских проблем и интенсивную междисциплинарную реабилитацию. Деятельность инсультного центра клиники «Оберіг» подтверждает возможность создания в Украине комплексного инсультного блока и достижения лучших результатов лечения инсульта в стационаре.