Cerebral ischemia and atrial fibrillation

Kelley, Roger E.; Berger, Joseph; Alter, Milton; Kovacs, Andrew G.

doi:10.1212/wnl.34.10.1285

Cited by 73 publications

(23 citation statements)

References 6 publications

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“…Data on known stroke risk factors were collected, as described previously2: age, gender, history of hypertension (blood pressure ≥140/90 mm Hg at least twice before stroke or already under treatment with antihypertensive drugs), history of diabetes mellitus (fasting glucose level ≥126 mg/dL preprandial on 2 examinations, glucose level ≥200 mg/dL postprandial, HbA1c ≥6.5%, or under antidiabetic treatment), current cigarette smoking, past smoking (cessation <5 years earlier), hyperlipidemia (total cholesterol ≥200 mg/dL, triglyceride ≥140 mg/dL, or already under lipid‐lowering therapy), history of symptomatic ischemic heart disease (myocardial infarction, history of angina or existence of multiple lesions on thallium heart isotope scan, or evidence of coronary disease on coronary angiography), history of symptomatic peripheral arterial disease (intermittent claudication of presumed atherosclerotic origin; ankle/arm systolic blood pressure ratio <0.85 in either leg at rest; or history of intermittent claudication with previous leg amputation, reconstructive surgery, or angioplasty), alcohol abuse (≥300 g/week), obesity (body mass index ≥30), or previous stroke or transient ischemic attack [TIA]). White matter changes (leukoaraiosis defined on the first CT [or MRI] examination as ill‐defined and moderately hypodense [or hyperintensity on T2‐weighted MRI] areas of ≥5 mm, according to published criteria) were investigated 17.…”

Section: Methodsmentioning

confidence: 99%

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Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin‐K Oral Anticoagulants (RAF‐NOACs) Study

Paciaroni

Agnelli

Falocci

et al. 2017

JAHA

103

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BackgroundThe optimal timing to administer non–vitamin K oral anticoagulants (NOACs) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention.Methods and ResultsRecurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA 2 DS 2‐VASc score >4 and less reduced renal function. Thirty‐two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOACs within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated >14 days after acute stroke.ConclusionsIn patients with acute ischemic stroke and atrial fibrillation, treatment with NOACs was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days.

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Section: Methodsmentioning

confidence: 99%

“…Patients with acute ischemic stroke and nonvalvular atrial fibrillation (AF) are at high risk of early recurrence 1, 2. In these patients, anticoagulant therapy plays a major role in the prevention of recurrent ischemic stroke.…”

Section: Introductionmentioning

confidence: 99%

Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin‐K Oral Anticoagulants (RAF‐NOACs) Study

Paciaroni

Agnelli

Falocci

et al. 2017

JAHA

103

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“…[1][2][3][4][5][6][7][8] The reported risk of recurrent stroke varies between 10% and 20% during the first year. 9 -13 The risk of very early recurrence has been investigated in several studies 4 -6,10,11,14 -17 and varies between 0.1% and 1.3% per day during the first 2 weeks after the initial event.…”

mentioning

confidence: 99%

“…9 -13 The risk of very early recurrence has been investigated in several studies 4 -6,10,11,14 -17 and varies between 0.1% and 1.3% per day during the first 2 weeks after the initial event. 6,10,14,15 The striking variation between studies can be explained partly by differences in study design (some studies were retrospective and others prospective) and by differences in the study populations (some studies included AF patients with coexistent cardiac abnormalities and others only patients with "lone" AF). Several studies have reported higher case fatality and morbidity after an ischemic stroke among AF patients compared with patients in sinus rhythm.…”

mentioning

confidence: 99%

Risk of Early Death and Recurrent Stroke and Effect of Heparin in 3169 Patients With Acute Ischemic Stroke and Atrial Fibrillation in the International Stroke Trial

Saxena

Lewis

Berge

et al. 2001

Stroke

249

113

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Background and Purpose — We sought to investigate the apparently high risk of early death after an ischemic stroke among patients with atrial fibrillation (AF), identify the main factors associated with early death, and assess the effect of treatment with different doses of subcutaneous unfractionated heparin (UFH) given within 48 hours. Methods — We studied the occurrence of major clinical events within 14 days among 18 451 patients from the International Stroke Trial, first for all treatment groups combined. Then, among patients with AF, we examined the effects of treatment with subcutaneous UFH started within 48 hours and continued until 14 days after stroke onset. Results — A total of 3169 patients (17%) had AF. Seven hundred eighty-four patients were allocated to UFH 12 500 IU SC BID, 773 to UFH 5000 IU SC BID, and 1612 to no heparin. Within each of these groups, half of the patients were randomly assigned to aspirin 300 mg once daily. Compared with patients without AF, patients with AF were more likely to be female (56% versus 45%), to be old (mean age, 78 versus 71 years), to have an infarct on prerandomization CT (57% versus 47%), and to have impaired consciousness (37% versus 20%). The initial ischemic stroke type was more often a large-artery infarct (36% versus 21%). A lacunar stroke syndrome was less common (13% versus 26%). Death within 14 days was more common in patients with AF (17% versus 8%) and more often attributed to neurological damage from the initial stroke (10% versus 4%). The frequency of recurrent ischemic or undefined stroke was not significantly different (3.9% versus 3.3%). The proportion of AF patients with further events within 14 days allocated to UFH 12 500 IU (n=784), UFH 5000 IU (n=773), and to no-heparin (n=1612) groups were as follows: ischemic stroke, 2.3%, 3.4%, 4.9% ( P =0.001); hemorrhagic stroke, 2.8%, 1.3%, 0.4% ( P <0.0001); and any stroke or death, 18.8%, 19.4% and 20.7% ( P =0.3), respectively. No effect of heparin on the proportion of patients dead or dependent at 6 months was apparent. Conclusions — Acute ischemic stroke patients with AF have a higher risk of early death, which can be explained by older age and larger infarcts but not by a higher risk of early recurrent ischemic stroke, although slightly more patients with AF died from a fatal recurrent stroke of ischemic or unknown type (1.3% versus 0.9%). In patients with AF the absolute risk of early recurrent stroke is low, and there is no net advantage to treatment with heparin. These data do not support the widespread use of intensive heparin regimens in the acute phase of ischemic stroke associated with AF.

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“…[21][22][23] In the Framingham Heart Study, patients with atrial fibrillation had a nearly 5-fold increase in the risk of developing stroke, compared with those who did not have atrial fibrillation.9 Several other studies, however, probably owing to small sample sizes and few subjects who developed stroke, failed to reveal an association between atrial fibrillation and stroke.2425…”

Section: Discussionmentioning

confidence: 99%

Atrial fibrillation as a risk factor for stroke: a retrospective cohort study of hospitalized Medicare beneficiaries.

Yuan¹,

Bowlin²,

Einstadter³

et al. 1998

Am J Public Health

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OBJECTIVES: This study examined the relationship between atrial fibrillation and (1) stroke and (2) all-cause mortality. METHODS: All eligible Medicare patients older than 65 years of age hospitalized in 1985 were followed up for 4 years. Kaplan-Meier and Cox proportional hazards models were used for assessment of risk of stroke and mortality. RESULTS: A total of 4,282,607 eligible Medicare patients were hospitalized in 1985. The mean age was 76.1 (+/- 7.7) years; 58.7% were female; 7.2% were Black; and 8.4% had a diagnosis of atrial fibrillation. During the follow-up period, 66,063 patients (32.6/1000 person-years) developed nonembolic stroke and 7285 (3.6/1000 person-years) developed embolic stroke. After adjustment for age, race, sex, and comorbid conditions, atrial fibrillation remained a significant risk factor for both nonembolic stroke (relative risk [RR] = 1.56) and embolic stroke (RR = 5.80) and for mortality (RR = 1.31). Approximately 4.5% of nonembolic and 28.7% of embolic strokes among hospitalized Medicare patients aged 65 years and older were attributable to atrial fibrillation. CONCLUSIONS: This study demonstrates that atrial fibrillation is associated with an appreciable increase in the risk of stroke (both embolic and nonembolic) and in the risk of mortality from all causes.

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Cerebral ischemia and atrial fibrillation

Cited by 73 publications

References 6 publications

Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin‐K Oral Anticoagulants (RAF‐NOACs) Study

Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin‐K Oral Anticoagulants (RAF‐NOACs) Study

Risk of Early Death and Recurrent Stroke and Effect of Heparin in 3169 Patients With Acute Ischemic Stroke and Atrial Fibrillation in the International Stroke Trial

Atrial fibrillation as a risk factor for stroke: a retrospective cohort study of hospitalized Medicare beneficiaries.

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