Safety of Early Administration of Apixaban on Clinical Outcomes in Patients with Acute Large Vessel Occlusion

Yoshimura, Shinichi; Sakai, Nobuyuki; Imamura, Hirotoshi; Yamagami, Hiroshi; Tanaka, Kanta; Ezura, Masayuki; Nonaka, Tadashi; Matsumoto, Yasushi; Shibata, Masunari; Ohta, Hiroyuki; Morimoto, Masafumi; Fukawa, Norihito; Enomoto, Yukiko; Takeuchi, Masataka; Ota, Terukazu; Shimizu, Fuminori; Kimura, Naoto; Kamiya, Yuki; Shimamura, Norihito; Morimoto, Takeshi

doi:10.1007/s12975-020-00839-4

Cited by 12 publications

(7 citation statements)

References 23 publications

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“…Moreover, larger infarctions carry a heightened potential risk of sHT (4,22). In a previous observational study, the early use of apixaban within 2 days in AF stroke with concurrent large vessel occlusion demonstrated comparable safety to later use (23). However, dosing considerations arise for early apixaban initiation in patients with medium to large lesions.…”

Section: Discussionmentioning

confidence: 99%

Early apixaban administration considering the size of infarction and functional outcome in acute ischemic stroke

Lee,

Koo,

Kwon

et al. 2024

Front. Neurol.

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Background and purposeAtrial fibrillation-related stroke (AF-stroke) is associated with an adverse prognosis, characterized by a high incidence of progression, recurrence, and hemorrhagic transformation. Our study aims to investigate the potential benefits of stratified early administration of apixaban, taking into account infarct size during the acute phase, in order to enhance functional outcomes.MethodsWe conducted this study at a tertiary referral stroke center, enrolling acute AF-stroke patients who received apixaban during the acute phase. Infarct size was categorized as small, medium, or large based on diffusion-weighted imaging. Patients were divided into two groups: standard initiation (apixaban initiation based on guidelines, i.e., small: 4 days, medium: 7 days, large: 14 days after stroke) and early initiation (initiation before guideline recommendations) groups. We compared favorable outcomes (modified Rankin scale score ≤ 2) at 3 months post-stroke, stroke progression, early recurrence, and symptomatic hemorrhagic transformation (sHT) between the groups.ResultsOut of 299 AF-stroke patients, 170 (56.9%) were in the early initiation group. A favorable outcome was observed in 105 (61.8%) patients in the early initiation group and 62 (48.1%) patients in the standard initiation group (p = 0.019). Stroke progression or early recurrence occurred less frequently in the early initiation group (4.7% versus 13.2%, p = 0.007). Nevertheless, no difference in sHT was noted between the groups. Early initiation of apixaban was independently associated with favorable outcomes (odds ratio: 2.75, 95% confidence interval: 1.44–5.28, p = 0.002).ConclusionOur findings suggest that early initiation of apixaban, tailored to infarct size, could serve as a viable strategy to enhance functional outcomes. This approach may potentially decrease stroke progression and early recurrence without elevating the risk of sHT.

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Section: Discussionmentioning

confidence: 99%

Early apixaban administration considering the size of infarction and functional outcome in acute ischemic stroke

Lee,

Koo,

Kwon

et al. 2024

Front. Neurol.

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“…Several observational studies have also reported outcomes according to anticoagulation timing (Supplementary Table 1). Collectively, these studies suggest that early anticoagulation with a NOAC is not associated with a high risk of intracranial haemorrhage, and that this risk is low compared to that of recurrent ischaemic stroke (77)(78)(79)(80)(81)(82)(83). Unexpectedly, several studies of these studies found numerically higher intracranial haemorrhage rates with more delayed anticoagulation, or similar or higher rates of recurrent ischaemia in early treatment groups (80)(81)(82)(83).…”

Section: Current Evidencementioning

confidence: 95%

“…Collectively, these studies suggest that early anticoagulation with a NOAC is not associated with a high risk of intracranial haemorrhage, and that this risk is low compared to that of recurrent ischaemic stroke (77)(78)(79)(80)(81)(82)(83). Unexpectedly, several studies of these studies found numerically higher intracranial haemorrhage rates with more delayed anticoagulation, or similar or higher rates of recurrent ischaemia in early treatment groups (80)(81)(82)(83). Given substantial imbalances in stroke severity, size and the presence of haemorrhagic transformation between groups, these results are likely to be confounded by treatment bias.…”

Section: Current Evidencementioning

confidence: 99%

Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges

Best

Cardus

Klijn³

et al. 2022

J Neurol Neurosurg Psychiatry

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Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.

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“…ALVO, which took place at 38 centers in Japan from July 2016 to February 2018, is a historical and prospective multicenter registry that recruited acute stroke patients with LVO or intra-/extracranial artery stenosis (>50%) who initiated apixaban within 14 days after the onset of NVAF. The full eligibility criteria have been previously published [18]. We included peripheral artery occlusions such as M2-3, A1-2, or P1-2.…”

Section: Methodsmentioning

confidence: 99%

“…In the Apixaban on clinical outcome of patients with Large Vessel Occlusion or stenosis (ALVO) trial, we reg-istered NVAF patients with acute LVO or intra-/extracranial artery stenosis (more than 50% stenosis) who were administered a DOAC (apixaban) within 14 days after onset and followed them for 1 year [18]. Many NVAF patients included in this study had only acute LVO, but some NVAF patients had intra-/extracranial artery stenosis.…”

Section: Introductionmentioning

confidence: 99%

Safety of Apixaban Monotherapy for Non-Valvular Atrial Fibrillation-Related Acute Stroke with Intra-/Extracranial Artery Stenosis

et al. 2022

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Introduction: We investigated whether apixaban is safe for the prevention of further adverse events in non-valvular atrial fibrillation (NVAF) patients with intra-/extracranial artery stenosis (Stenosis group) compared with acute large vessel occlusion without intra-/extracranial artery stenosis (No stenosis group). We also examined whether combination therapy using apixaban and antiplatelet is safe. Methods: ALVO (Apixaban on clinical outcome of patients with Large Vessel Occlusion [LVO] or stenosis) was a historical and prospective multicenter registry at 38 centers in Japan. Patients with NVAF and acute LVO or stenosis who received apixaban within 14 days after onset were included. We conducted the post hoc analysis using the ALVO dataset. We compared patients with stenosis versus those without stenosis in terms of the primary outcome, which was defined as a composite of all-cause death, major bleeding events, and ischemic events 365 days after onset. Results: Of the 662 patients, 54 (8.2%) patients were classified into the Stenosis group, and 104 patients of the total (16%) reached the primary outcome. The cumulative incidence of primary outcome was not significantly different between the No stenosis and the Stenosis groups (hazard ratio [HR] 1.2, 95% confidence interval [CI]: 0.64–2.4; p = 0.52). Even after adjustment for predictive clinical variates, no significant difference in the primary endpoint between the No stenosis and the Stenosis groups was shown (adjusted HR 1.2, 95% CI: 0.59–2.5; p = 0.60). Fifty patients (7.6%) used an antiplatelet with apixaban. Among the Stenosis group patients, the cumulative incidence of the primary outcome was significantly higher among patients treated with an antiplatelet and apixaban (HR 3.5, 95% CI: 1.0–12; p = 0.048). Conclusion: Apixaban monotherapy appears safe for the prevention of further adverse events in the Stenosis group patients similar to the No stenosis group patients. Concomitant use of an antiplatelet might not be favorable in patients with stenosis.

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Safety of Early Administration of Apixaban on Clinical Outcomes in Patients with Acute Large Vessel Occlusion

Cited by 12 publications

References 23 publications

Early apixaban administration considering the size of infarction and functional outcome in acute ischemic stroke

Early apixaban administration considering the size of infarction and functional outcome in acute ischemic stroke

Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges

Safety of Apixaban Monotherapy for Non-Valvular Atrial Fibrillation-Related Acute Stroke with Intra-/Extracranial Artery Stenosis

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