Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants

Purrucker, Jan; Hölscher, Kyra; Kollmer, Jennifer; Ringleb, Peter A.

doi:10.3390/jcm9092938

Cited by 25 publications

(35 citation statements)

References 30 publications

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“…Recent data from Purrucker et al suggest that non-adherence to medication, under-dosage of anticoagulants, or their temporary discontinuation frequently precede AF-related stroke despite OAC. 9 This is in line with our findings that suggest that 65.93% of the patients on VKA that experienced an ischemic stroke were not on therapeutic range. Hence, it is of paramount importance to investigate the individual circumstances of a stroke occurring on anticoagulants and to address the multiplicity of underlying factors in subsequent prevention.…”

Section: Discussionsupporting

confidence: 91%

“…Potential causes include inadequate dosing and non‐adherence to medication as well as competing other stroke etiologies, such as small vessel disease or large artery atherosclerosis. Insight into stroke subtype, pattern and location of cerebral infarction and potentially competing non‐cardioembolic stroke mechanisms of these patients is sparse 9,10 …”

Section: Introductionmentioning

confidence: 99%

“…Insight into stroke subtype, pattern and location of cerebral infarction and potentially competing non-cardioembolic stroke mechanisms of these patients is sparse. 9,10 Recent evidence suggests that the rate of recurrent ischemic stroke in AF patients who were anticoagulated is 8.9% annually. 11 Unfortunately, best preventative management after these events is uncertain.…”

mentioning

confidence: 99%

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Ischemic stroke in oral anticoagulated patients with atrial fibrillation

D’Anna

Filippidis

Harvey

et al. 2021

Acta Neuro Scandinavica

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Oral anticoagulation is recommended by American and European guidelines to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation (AF). [1][2][3] Direct oral anticoagulants (DOACs) are now generally preferred over vitamin K antagonists (VKA) because randomized clinical trials have shown that DOACs have a lower risk of intracranial hemorrhage and are superior or non-inferior to VKA in preventing thromboembolism in direct comparisons. [4][5][6][7] However, despite the oral anticoagulant treatment, 1-2% of AF patients suffer

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Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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Ischemic stroke in oral anticoagulated patients with atrial fibrillation

D’Anna

Filippidis

Harvey

et al. 2021

Acta Neuro Scandinavica

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“…A recent (2014-2019) Swiss cohort study showed that 18% of all AF patients with ischemic stroke had been on prior VKA therapy and 20% on orior DOAC therapy [16••]. Reasons for ischemic stroke despite anticoagulation include competing stroke etiology or mechanisms (e.g., large-artery atherosclerosis, small-vessel disease, active malignancy [17][18][19][20][21], medication error (e.g., non-adherence, inappropriate DOAC dosage, or subtherapeutic INR) as well as cardioembolism despite anticoagulant therapy. However, recent studies found that prior therapeutic anticoagulation with VKA or DOAC was associated with lower stroke severity [16 Intravenous thrombolysis with alteplase is the gold standard in the treatment of acute ischemic stroke with significant improvement in functional outcome [23][24][25][26].…”

Section: Introductionmentioning

confidence: 99%

Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option?

Siller

Chandratheva

Bücke

et al. 2021

Curr Treat Options Neurol

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Purpose of Review Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients. Recent Findings Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients. Summary IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.

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“…Nevertheless, while the relative risk of hemorrhagic strokes has been halved by using NOACs as compared to warfarin, a vitamin K antagonist (VKA), the rate of ischemic stroke has remained largely unchanged [ 1 ]. Consequently, acute ischemic stroke (AIS) develops frequently despite oral anticoagulation [ 2 , 3 ]. Current evidence about the optimal treatment strategies in patients with AIS under therapy with NOACs is still limited [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

Challenges of Acute Ischemic Stroke Treatment in Orally Anticoagulated Patients via Telemedicine

Escolà

Nagel

Panitz

et al. 2021

JCM

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Background: Managing acute ischemic stroke (AIS) in patients receiving treatment with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs) is difficult and the challenge this poses for stroke telemedicine remains unexplored. Methods: We analyzed data from a random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017. Management of patients suffering AIS with and without prior oral anticoagulation treatment was characterized, including potential vs. actual treatment with intravenous thrombolysis (IVT) and reasons for withholding it. Results: n = 359 patients had suffered an AIS, of whom 63 (17.5%) were under treatment with oral anticoagulants (VKA, n = 24; NOAC, n = 39). Administration of IVT was more common in patients who had not received prior oral anticoagulation treatment (20.3% vs. 3.2%, p < 0.001). NOAC intake was the primary reason for withholding IVT in 37% of orally anticoagulated patients who were found potentially eligible for IVT. Furthermore, patients under oral anticoagulation tended to be transported to the comprehensive stroke center more often (23.8% vs. 13.9%, p = 0.056). Conclusions: AIS in patients on oral anticoagulation treatment is a frequent reason for telestroke consultation, and NOAC intake constitutes an important barrier to administering IVT.

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Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants

Cited by 25 publications

References 30 publications

Ischemic stroke in oral anticoagulated patients with atrial fibrillation

Ischemic stroke in oral anticoagulated patients with atrial fibrillation

Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option?

Challenges of Acute Ischemic Stroke Treatment in Orally Anticoagulated Patients via Telemedicine

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