Efficacy and Safety of Anticoagulant Treatment in Acute Cardioembolic Stroke

Abstract

Background and Purpose-The role of anticoagulant treatment for acute cardioembolic stroke is uncertain. We performed an updated meta-analysis of all randomized trials to obtain the best estimates of the efficacy and safety of anticoagulants for the initial treatment of acute cardioembolic stroke. Methods-Using electronic and manual searches of the literature, we identified randomized trials comparing anticoagulants (unfractionated heparin or low-molecular-weight heparin or heparinoids), started within 48 hours, with other treatments (aspirin or placebo) in patients with acute ischemic cardioembolic stroke. Two reviewers independently selected studies and extracted data on study design, quality, and clinical outcomes, including death or disability, all strokes, recurrent ischemic stroke, and cerebral symptomatic bleeding. Odds ratios for individual outcomes were calculated for each trial and data from all the trials were pooled using the Mantel-Haenszel method. Results-Seven

Thirty‐day recurrence after ischemic stroke or TIA

“…Many of these studies were however performed before anticoagulation was implemented as standard practice. Studies investigating the effect of aspirin vs. low molecular‐weight heparin in the early phase have generally shown no benefit of anticoagulation, suggesting that early re‐embolization is rare (Paciaroni, Agnelli, Micheli, & Caso, 2007). Recently published data from our stroke registry show no correlation between time to MRI and frequency of multiple acute cerebral infarcts in cardio embolic IS, suggesting that cardiogenic emboli seem to happen as a shower and not successively (Novotny, Khanevski, Thomassen, Waje‐Andreassen, & Naess, 2017).…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Kwestia, czy można by stosować swoiste antidota odwracające działanie NOAC [475], a potem systemową trombolizę, wymaga zbadania. Trombektomię można wykonywać u pacjentów otrzymują- [477]. Wydaje się prawdopodobne, że w pierwszych dniach po wystąpieniu dużego udaru ryzyko krwawienia podczas parenteralnego leczenia przeciwzakrzepowego przewyższa korzyść w postaci zapobiegania ponownemu udarowi, natomiast pacjenci z TIA lub małym udarem mogą odnosić korzyści z wczesnego (natychmiastowego) rozpoczynania leczenia przeciwzakrzepowego lub jego kontynuacji.…”

Guidelines for acute ischemic stroke treatment: part II: stroke treatment

“…evaluated in a recent meta-analysis 3 which failed to show any significant reduction in recurrence of ischemic stroke or any change in mortality and disability rates. A study of heparin administration in the hyperacute phase (within 3 hours of symptom onset) of acute nonlacunar hemispheric infarction showed that more patients on anticoagulation therapy reached the endpoint of functional independence (38.9 versus 28.6%; p=0.025), but had a higher rate of symptomatic cerebral hemorrhage (6.2 versus 1.4%; p=0.008), with no increase in mortality 4 .…”