Anticoagulation Type and Early Recurrence in Cardioembolic Stroke

Abstract

Background and Purpose: In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage. Methods: We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations. Results: We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01–7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63–2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29–0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22–1.48]). Conclusions: Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

Analysis of medical service utilization for post-stroke sequelae in Korea between 2016 and 2018: a cross-sectional study

“…Antithrombotic/anticoagulant agents were prescribed at the second highest frequency, and are generally used for the treatment of ischemic stroke and for secondary prevention of intracerebral hemorrhage 64 , 65 . In addition, {Viswanathan, 2006 #94} vasopressor/blood circulation agents are used to regulate hypertension, which is a risk factor of stroke 66 .…”

Feasibility of the Big 5—Jena eCS Protocol

“…Irrespective of the abovementioned limitations, the cardiac imaging included in our extended cardio-stroke protocol also allows the simultaneous evaluation of atherosclerotic disease as another embolism substrate [ 3 , 4 , 34 , 35 ], which could have important therapeutic implications in embolic stroke associated with atrial fibrillation [ 36 – 38 ]. The non-invasive character of CT combined with its reproducibility and the other advantages mentioned above highlight this technique as a reliable option in the assessment of acute stroke patients in the ED [ 8 , 25 ].…”

Direct Oral Anticoagulants after Ischemic Stroke: Which Patient? Which Drug? And How Early?

“…The second study included 1,251 patients with AF and stroke from the United States. 13 Follow-up was shorter (90 days), and the median time between strokes to therapeutic international normalized ratio was 8 days (interquartile range: 4-13). In contrast with the prior study, there were fewer recurrent ischemic strokes in the DOAC group (HR: 0.51; 95% CI: 0.29-0.87), whereas the risk of ICH did not differ compared with the VKA group (HR: 0.57; 95% CI: 0.22-1.48).…”