Antithrombotic therapy for ischaemic stroke patients with AF/RHD in West China daily practice

Abstract

Background and Objective:

Although, current evidence-based guidelines advocate anticoagulation as a strong recommendation in IS patients with AF/RHD, the underuse of anticoagulation in IS patients with AF/RHD has been found in clinical practice worldwide. Nevertheless, there was little information about implementation of antithrombotic therapy to prevent stroke for patients with AF and/or RHD in daily practice in West China. Our study determined to clarify the patterns, adherence and comparative effect of antithrombotic treatment during 1-year follow-up in IS patients with AF and/or RHD.

Method:

Consecutive patients with acute IS and AF/RHD admitted to Department of Neurology, West China Hospital from November 2010 to October 2011 were included in the study.

Results:

155 consecutive patients were analysed in this study. One hundred thirteen patients have been diagnosed as AF and/or RHD before admission. Of these, 49 (43.4%) patients were receiving antithrombotic therapy before the time of admission, including nine (8.0%) patients receiving warfarin. At 12?months after stroke onset, 109 (81.3%) patients were on antithrombotics, and 46 (34.3%) patients were on warfarin alone. The persistence rate of warfarin use at 1?year was 77.8%. Moreover, there were 80 (81.6%) patients never starting to use warfarin. Compared with no antithrombotic therapy, anti-platelets and warfarin reduced death risk significantly during 1-year after stroke onset (P?=?0.005).

Conclusion:

Our study suggests that overall real-world use of warfarin in IS patients with AF and/or RHD is low before and after admission in West China. Implementation study on this respect should be conducted in this area to improve the daily practice.     

缺血性卒中/TIA患者抗栓药物的使用及影响因素分析：中国七城市门诊连续病例的横断面调查

目的 评估中国缺血性卒中(IS)或短暂性脑缺血发作（TIA）患者应用抗血栓药物（包括抗血小板药物和抗凝药物）的现况，并分析其影响因素。方法 采用横断面研究方法，调查2006年7月1日至8月15日期间，中国主要城市二、三级医院神经内科门诊连续IS或TIA患者近期的抗血栓药物使用情况。22家医院参加调查，总计2384例卒中患者连续入选；有3家不符合中心入选标准被除外，最后19家医院的资料被采用，总计有2283例卒中患者的数据纳入分析中。结果 2283例卒中患者中，使用阿司匹林者占71.9％，使用阿司匹林+氯吡格雷占4.2％，使用氯吡格雷者占7.3％，各种抗血小板药物合计例数占75.6％。伴心房颤动的81例卒中患者中，使用华发林者占17.3％。医疗保险[比值比（OR）1.473，95%可信区间（CI）1.088～1.994]、公费医疗（OR 1.632，95%CI 1.029～2.589）、月均收入≥500元以上（OR 2.136，95%CI 1.508～3.026）、高血压（OR 1.463，95%CI 1.159～1.847）和脂代谢紊乱（OR 1.499，95%CI 1.187～1.893）是卒中患者接受抗血小板药物的促进因素。患者年龄≥75岁（OR 0.701，95%CI 0.498～0.988）及改良的Rankin评分4～5分（OR 0.684，95%CI 0.486～0.965）是用药的阻碍因素。结论 中国大城市二、三级医院IS和TIA患者的抗血栓治疗现状不容乐观，各类抗血栓药物应用的比例较低，为改善以上状况，亟待探索有效的改进模式，缩短临床实践与指南间的差距。     

Non-vitamin K oral anticoagulants as first-line regimen for acute ischemic stroke with non-valvular atrial fibrillation

PurposeThere are various patterns in determining the choice of the first-line antithrombotic agent for acute stroke with non-valvular atrial fibrillation. We investigated the efficacy and safety of non-vitamin K oral anticoagulants as first-line antithrombotics for patients with acute stroke and non-valvular atrial fibrillation.Materials and MethodsPatients with non-valvular atrial fibrillation and ischemic stroke or transient ischemic attack within 24 h from stroke onset were included. On the basis of the first regimen used and the regimen within 7 days after admission, the study population was divided into three groups: 1) antiplatelet switched to warfarin (A-W), 2) antiplatelet switched to NOAC (A-N), and 3) NOAC only (N only). We compared the occurrence of early neurologic deterioration, symptomatic intracranial hemorrhage, systemic bleeding, and poor functional outcome at 90 days.ResultsOf 314 included patients, 164, 53, and 97 were classified into the A-W, A-N, and N only groups, respectively. Early neurologic deterioration was most frequently observed in the A-W group (9.1%), followed by the A-N (5.7%) and N only (1.0%) groups (p = 0.017). Multivariable analysis adjusting for potential confounders demonstrated that the N only group was independently associated with a lower rate of early neurologic deterioration (odds ratio [OR] 0.104, 95% CI 0.013-0.831) or poor functional outcome at 90 days (OR 0.450, 95% CI 0.215-0.940) than the A-W group. However, the rate of symptomatic intracranial hemorrhage or any systemic bleeding event did not differ among the groups.ConclusionUsing non-vitamin K oral anticoagulants as the first-line regimen for acute ischemic stroke may help prevent early neurologic deterioration without increasing the bleeding risk.     

Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation – K-PLUS registry

BackgroundStroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs).Material and methodsWe collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset.ResultsA total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40–0.78) in the DOACs group, while it was 0.98 (0.77–1.24) in the warfarin group and 0.94 (0.72–1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups.ConclusionPreceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.     

Adequate Adherence to Direct Oral Anticoagulant is Associated with Reduced Ischemic Stroke Severity in Patients with Atrial Fibrillation

BackgroundThe impact of adherence to direct oral anticoagulants (DOACs) is unknown. We aimed to assess the effects of preceding anticoagulation treatment on neurologic severity at admission and functional outcomes at discharge in patients with atrial fibrillation (AF) who developed acute ischemic stroke.MethodsWe retrospectively assessed consecutive patients with acute ischemic stroke and AF. Adherence to DOACs was assessed using the 4-item Morisky Medication Adherence Scale. Associations between preceding DOAC treatment and stroke severity at admission and functional outcomes at hospital discharge were examined.ResultsOf 387 patients with AF and acute ischemic stroke, 248 (64.1%) were not administered an anticoagulant before stroke onset, 95 (24.5%) had subtherapeutic warfarin with an international normalized ratio less than 2 at the time of stroke, 16 (4.1%) had therapeutic warfarin, 6 (1.6%) had DOACs with nonadherence, and 22 (5.7%) had DOACs with adequate adherence. Multivariate analysis showed that DOAC treatment with adequate adherence was associated with lower odds of severe stroke (National Institute of Health Stroke Scale ≥10 at admission) (odds ratio, .24; 95% confidence interval, .03-.98; P = .04) and higher odds of excellent recovery (modified Rankin Scale score, 0-1 at discharge) (odds ratio, 4.89; 95% confidence interval, 1.51-20.6; P < .01) compared with no anticoagulation therapy.ConclusionsPreceding DOAC treatment with adequate adherence has beneficial effects on stroke severity at admission and functional outcome at discharge in patients with AF. Hence, our results encourage an increased effort to bolster adherence to DOACs in patients with AF.     

Factors affecting self-reported bleeding acceptance in acute ischemic stroke survivors on various types of antithrombotic therapy

ObjectivesPrior ischemic cerebrovascular event and younger age have been shown to increase bleeding acceptance among anticoagulated outpatients with atrial fibrillation (AF). We sought to determine factors affecting bleeding acceptance in acute ischemic stroke (AIS) survivors on various types of antithrombotic therapy.Materials and MethodsWe enrolled 173 consecutive patients hospitalized for AIS (aged 68.2±11.7 years, 54.9% male), including 54 (31.2%) with AF, who had favorable functional outcome. On discharge, the Bleeding ratio, defined as the declared maximum number of major bleedings that a patient is willing to accept to prevent one major stroke, was evaluated. We assessed the predicted bleeding risk in non-cardioembolic and cardioembolic stroke survivors using S₂TOP-BLEED and HAS-BLED scores, respectively.ResultsPatients with the low Bleeding ratio, defined as 5 (median) or less accepted bleeds (n=92; 53.2%), were older and more likely to receive thrombolysis and/or thrombectomy, with no impact of previous stroke. Prior major bleed (odds ratio [OR] 4.67; 95% confidence interval [CI] 0.92-23.72), AF with use of oral anticoagulants (OR 2.35, 95% CI 1.12-4.93), reperfusion treatment (OR 1.95, 95% CI 1.02-3.76), and hospitalization ≤10 days (OR 4.56; 95% CI 1.50-13.87) were associated with the low Bleeding Ratio. Prior use of anticoagulants or aspirin as well as HAS-BLED and S₂TOP-BLEED scores did not affect the bleeding acceptance.ConclusionsLower bleeding acceptance declared on discharge by AIS survivors is determined by prior bleeding, anticoagulation in AF, reperfusion treatment, and duration of hospitalization, which might affect medication adherence. The results might help optimize post-discharge management and educational efforts in patients on antithrombotic therapy.     

Low-dose warfarin in atrial fibrillation leads to more thromboembolic events without reducing major bleeding when compared to adjusted-dose--a meta-analysis

The use of warfarin with a range INR of 2.0-3.0 is recommended in prevention of stroke for nonvalvular atrial fibrillation (AF) patients, in particular those older than 75 years. The risk of bleeding that is associated with this range of INR has led to evaluate lower ranges (low-dose or fixed minidose) in terms of risks and benefits. A meta-analysis of all randomized controlled trials evaluating 'low-intensity' 'minidose' or 'low-dose anticoagulant' treatment for prevention of thromboembolic events in AF was conducted by two independent reviewers. Study quality was evaluated in a blinded fashion. Four original studies were retrieved. Outcome events were determined in various treatment groups: ischemic stroke, systemic embolism, thromboses (ischemic stroke, systemic embolism or myocardial infarction), vascular death, major hemorrhage and hemorrhagic death. Results obtained with a random effects model were expressed as a common relative risk. Adjusted-dose warfarin compared with lower dose warfarin (INR < or = 1.6) in 2108 randomised patients significantly reduced the risk of any thrombosis: Relative risk (RR): 0.50 (95% CI; 0.25 to 0.97). The RR was 0.46 (95%CI; 0.2 to 1.07) for ischemic stroke. Inversely lower dose did not statistically decrease the risk for major hemorrhage compared to adjusted-dose: RR adjusted-dose vs lower dose: 1.23 (95% CI; 0.67-2.27). The RR was 0.97 (95 % CI 0.27-3.54) for hemorrhagic death. Our meta-analysis showed that adjusted-dose compared with low-dose or minidose warfarin therapy (INR < or =1.6) was more effective to prevent ischemic thromboembolic events in patients with atrial fibrillation.     

Antithrombotic management after an ischemic stroke in French primary care practice: results from three pooled cross-sectional studies

BACKGROUND AND PURPOSE: We aimed at quantifying and explaining the underuse of antithrombotic treatments after an ischemic stroke in patients seen in French primary care. METHODS: We pooled all ischemic stroke patients included in 3 observational primary care-based observational studies. French general practitioners and cardiologists recruited 14,544 patients with atherothrombotic disease including 4,322 with an ischemic stroke. Antithrombotic therapies and risk factors were prospectively recorded. Patients with atrial fibrillation (AF) were considered appropriate for oral anticoagulants (OAC) and those without AF for antiplatelet drugs. RESULTS: Out of the 4,322 stroke patients, 3,732 (86.3%) were taking at least one antithrombotic drug. Among the 765 patients with AF, 333 (43.5%) received OAC and 2,718 (86.9%) out of the 3,129 patients appropriate for antiplatelet drug were taking antiplatelet drug. Multivariate analyses did not single out any risk factors for nonuse of OAC and showed that female sex (OR = 1.48; IC 95%: 1.14-1.92) was associated with nonuse of antiplatelet drugs. Conversely, past myocardial infarction (OR = 0.44; IC 95%: 0.26-0.71) and hypercholesterolemia (OR = 0.64; IC 95%: 0.50-0.81) were associated with appropriate use of antiplatelet drugs. CONCLUSION: More than 50% of stroke patients with AF do not receive OAC and 15% of those without AF do not receive antiplatelet drugs. These findings are not satisfactorily explained by the main patients' characteristics and practitioner's speciality and underline the complexity of the process which allows the transfer of scientific evidence in clinical practice.     

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

Background/ObjectiveWhile postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.MethodsA cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.ResultsIncidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3–7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06–6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95–27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5–6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45–144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99–21.29]; p = .002) were at significantly higher risk of death within the 30-day period.ConclusionIn this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.     

Antithrombotic and antihypertensive management 3 months after ischemic stroke : a prospective study in an inner city population

BACKGROUND AND PURPOSE: We sought to examine the frequency, predictors, and effects of nontreatment with antithrombotic and antihypertensive therapies 3 months after ischemic stroke. METHODS: The population-based South London Community Stroke Register prospectively collected data on first-in-a-lifetime strokes between 1995 and 1997. Among patients registered with ischemic stroke, treatment status with antithrombotic and antihypertensive therapies was examined 3 months after the event. RESULTS: In a cohort of 457 patients with ischemic stroke, 393 (86.0%) were considered appropriate for antiplatelet medication, 32 (7.0%) for anticoagulant medication, and 254 (55.9%) for antihypertensive medication. The rates of nontreatment observed 3 months after the event were 24.4% for antiplatelet, 59.4% for anticoagulant, and 29.5% for antihypertensive medication. Independent risk factors for nontreatment with antithrombotic therapies (antiplatelets and anticoagulants) were the subtype of stroke (nonlacunar infarct: OR=1. 60, 95% CI 1.07 to 2.54), stroke severity measured by the Glasgow Coma Scale (GCS) score (GCS 相似文献   

GWAS-Supported <Emphasis Type="Italic">CRP</Emphasis> Gene Polymorphisms and Functional Outcome of Large Artery Atherosclerotic Stroke in Han Chinese

Elevated C-reactive protein (CRP) levels increase the risk of poor functional disability in patients with ischemic stroke (IS). This study aimed to investigate the association between CRP gene polymorphisms and 3-month functional disability of large artery atherosclerotic (LAA) stroke in Han Chinese. Patients with first-ever LAA IS were prospectively enrolled in Nanjing Stroke Registry Program between August 2013 and October 2015. Five single-nucleotide polymorphisms (SNPs) (rs876537, rs2794520, rs3093059, rs7553007 and rs11265260) in CRP gene related to CRP levels in Asian by genome-wide association study were genotyped. The functional outcome at 3 months after the index stroke was assessed by the modified Rankin scale. Associations between genotypes and functional outcome of LAA IS were analyzed with logistic regression model. A total of 690 eligible patients (507 males) were evaluated. SNPs rs11265260 (multivariate-adjusted, p?=?0.022), rs2794520 (multivariate-adjusted, p?=?0.036) and rs3093059 (multivariate-adjusted, p?=?0.027) were significantly associated with elevated CRP in acute IS. Two SNPs, rs3093059 (dominant model: adjusted OR 2.49; 95% CI 1.55–4.00; recessive model: adjusted OR 3.67; 95% CI 1.22–11.03) and rs11265260 (dominant model: adjusted OR 2.51; 95% CI 1.56–4.02; recessive model: adjusted OR 4.70; 95% CI 1.63–13.56) independently predicted 3-month poor outcome of first-ever LAA IS, after adjusting for covariates. In addition, haplotype analysis indicated that haplotype GCTGC (adjusted OR 1.76; 95% CI 1.05–2.95; p?=?0.031) increased the poor outcome risk. SNPs rs3093059 and rs11265260 in CRP gene may influence the 3-month functional outcome of first-ever LAA IS in Han Chinese.     

Sleep-disordered breathing among acute ischemic stroke patients in Brazil

ObjectivesSleep-disordered breathing (SDB) is very common in acute stroke patients and has been related to poor outcome. However, there is a lack of data about the association between SDB and stroke in developing countries. The study aims to characterize the frequency and severity of SDB in Brazilian patients during the acute phase of ischemic stroke; to identify clinical and laboratorial data related to SDB in those patients; and to assess the relationship between sleep apnea and functional outcome after six months of stroke.MethodsClinical data and laboratorial tests were collected at hospital admission. The polysomnography was performed on the first night after stroke symptoms onset. Functional outcome was assessed by the modified Rankin Scale (mRS).ResultsWe prospectively evaluated 69 patients with their first-ever acute ischemic stroke. The mean apnea–hypopnea index (AHI) was 37.7 ± 30.2. Fifty-three patients (76.8%) exhibited an AHI ≥ 10 with predominantly obstructive respiratory events (90.6%), and thirty-three (47.8%) had severe sleep apnea. Age (OR: 1.09; 95% CI: 1.03–1.15; p = 0.004) and hematocrit (OR: 1.18; 95% CI: 1.03–1.34; p = 0.01) were independent predictors of sleep apnea. Age (OR: 1.13; 95% CI: 1.03–1.24; p = 0.01), body mass index (OR: 1.54; 95% CI: 1.54–2.18; p = 0.01), and hematocrit (OR: 1.19; 95% CI: 1.01–1.40; p = 0.04) were independent predictors of severe sleep apnea. The National Institutes of Health Stroke Scale (NIHSS; OR: 1.30; 95% CI: 1.1–1.5; p = 0.001) and severe sleep apnea (OR: 9.7; 95% CI: 1.3–73.8; p = 0.03) were independently associated to mRS >2 at six months, after adjusting for confounders.ConclusionPatients with acute ischemic stroke in Brazil have a high frequency of SDB. Severe sleep apnea is associated with a poor long-term functional outcome following stroke in that population.     

Prevalence and Predictors of Stroke in Patients with Crohn's Disease: A Nationwide Study

ObjectivesMounting evidence points to the microbiome as a susceptibility factor for neurological disorders. Patients with Crohn's disease (CD) are at higher ischemic stroke (IS) risk, but no large scale epidemiologic studies have identified risk factors for stroke in this population.Materials and MethodsWe analyzed the 2017 Nationwide Inpatient Sample (NIS) dataset to identify patients with a discharge diagnosis of Crohn's disease using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code K50.X. We identified patients with a primary/secondary discharge diagnosis of IS using ICD-10-CM code I63.X. We compared sociodemographic and clinical variables between stroke and non-stroke patients with CD. Logistic regression analysis was applied to identify factors associated with IS.ResultsOf 30,212 patients with CD, 369 (1.2 %) had a discharge diagnosis of IS. Older age (odds ratio [OR], 1.03 [95% CI, 1.02–1.04], top quartile income (OR, 1.58 [95% CI, 1.10–2.30]), and hospitalization in a South Atlantic (OR, 1.82 [95% CI, 1.11-3.14]), East South Central (OR, 2.30 [95% CI, 1.28-4.25]), or West South Central hospital (OR, 2.40 [95% CI, 1.39-4.28]) were independently associated with IS. Clinical variables independently associated with IS in patients with CD included: atrial fibrillation (OR, 1.66 [95% CI, 1.15-2.33]), atherosclerosis (OR, 2.41 [95% CI, 1.32-4.10]), hyperlipidemia (OR, 1.69 [95% CI, 1.33-2.15]), hypertension (OR, 1.53 [95% CI, 1.18-1.98]) and valvular disease (OR, 1.62 [95% CI, 1.01-2.48).ConclusionA subset of traditional stroke risk factors are associated with IS in patients with CD. CD patients with these conditions could be targeted for vascular risk reduction and surveillance.     

Thrombolytic therapy in ischemic stroke patients with pre-stroke depression in the telestroke vs non-telestroke

Background and PurposeThrombolysis therapy remains the gold standard in acute ischemic stroke treatment, and rates of treatment with rtPA in ischemic stroke patients with comorbid depression has yet to be fully investigated. This study aims to examine clinical risk factors associated with inclusion or exclusion for rtPA in acute ischemic stroke populations with pre-stroke depression in the telestroke versus a non-telestroke setting.MethodsWe collected retrospective data from a regional stroke registry for pre-stroke depressed ischemic stroke patients from January 2010 to June 2016. Logistic regression was used to determine demographic and baseline clinical risk factors associated with inclusion and exclusion from rtPA.Results. In the adjusted analysis, increasing age (OR = 1.064, 95% CI, 1.006-1.125, P = 0.029), improved ambulation (OR = 3.513, 95% CI, (0.855–14.436, P = 0.018) and sleep apnea (OR = 4.458, 95% CI, 0.731–27.182, P = 0.05) were associated with inclusion for rtPA, while Caucasian race (OR = 0.119, 95% CI, 0.0168–0.908, P = 0.040), systolic blood pressure (OR = 0.945, 95% CI, 0.906–0.985, P = 0.008), and direct admission (OR = 0.028, 95% CI, 0.003–0.317, P = 0.004) were associated with exclusion from rtPA. In the telestroke setting, INR (OR = 1.016, 95% CI, 0–5.393, P = 0.163) was not significantly associated with rtPA inclusion or exclusion.ConclusionIdentifying contraindicators associated with exclusion from rtPA is significant to improve the use thrombolytic therapy in the telestroke and non telestroke settings.     

Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients

Atrial fibrillation (AF) carries an increased risk of ischaemic stroke, and oral anticoagulation with warfarin can reduce this risk. The objective of this study was to evaluate the association between time in therapeutic International Normalised Ratio (INR) range when receiving warfarin and the risk of stroke and mortality. The study cohort included AF patients aged 40 years and older included in the UK General Practice Research Database. For patients treated with warfarin we computed the percentage of follow-up time spent within therapeutic range. Cox regression was used to assess the association between INR and outcomes while controlling for patient demographics, health status and concomitant medication. The study population included 27,458 warfarin-treated (with at least 3 INR measurements) and 10,449 patients not treated with antithrombotic therapy. Overall the warfarin users spent 63% of their time within therapeutic range (TTR). This percentage did not vary substantially by age, sex and CHA2DS2-VASc score. Patients who spent at least 70% of time within therapeutic range had a 79% reduced risk of stroke compared to patients with ≤30% of time in range (adjusted relative rate of 0.21; 95% confidence interval 0.18-0.25). Mortality rates were also significantly lower with at least 70% of time spent within therapeutic range. In conclusion, good anticoagulation control was associated with a reduction in the risk of stroke.     

Anticoagulation-related reduction of first-ever stroke severity in Chinese patients with atrial fibrillation

Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and warfarin related anticoagulation has been recommended as an effective treatment for stroke prevention. We aimed to determine whether pre-stroke oral anticoagulation therapy would reduce initial stroke severity in AF patients with first-ever ischemic stroke. We identified consecutive patients who developed first-ever ischemic stroke and were eligible for anticoagulation therapy from the China National Stroke Registry. Multivariate logistic analysis was used to assess the association between warfarin usage and initial stroke severity, measured by the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). Of 9519 patients, 1140 (11.98%) had AF, including 440 (38.6%) without known AF before presentation, 561 (49.2%) with known AF but not taking warfarin, and 139 (12.2%) with known AF who were taking warfarin. Compared to patients with known AF but not on warfarin, the odds ratio (OR) of having a major stroke (NIHSS ⩾4) was lower in patients with known AF who were on warfarin (OR = 0.68; 95% confidence interval [CI] 0.57–0.84). The OR of developing a severe coma (GCS 3–8) was also reduced in the warfarin group (OR = 0.71; 95% CI 0.56–0.91). In conclusion, pre-stroke warfarin therapy lowered the severity of the first-ever ischemic stroke in patients with known AF. Considering its efficacy in stroke prevention and the significant under-usage of warfarin in China, the primary prevention of stroke in AF patients should be reinforced.     

Anticoagulation under-utilization in atrial fibrillation patients is responsible for a large proportion of strokes requiring endovascular therapy

ObjectivesAtrial fibrillation (AF) is responsible for 30-50% of large strokes requiring endovascular thrombectomy (EVT). Anticoagulation (AC) underutilization is a common source of AF-related stroke. We compared antithrombotic medications among stroke patients with AF that did or did not undergo EVT to determine if AC underutilization disproportionately results in strokes requiring EVT, while quantifying the proportion of likely preventable thrombectomies.MethodsThis retrospective single-center cohort included consecutive patients admitted with acute ischemic stroke between 2016 and 2021. Patients were categorized based on the presence of AF, and pre-admission antithrombotic medications were compared between those who underwent EVT and those who didn't. The reason for not being on AC was abstracted from the medical record, and patients were categorized as either AC eligible or AC contraindicated.ResultsOf 3092 acute ischemic stroke patients, 644 had a history of AF, 213 of whom underwent EVT. Patients who required EVT were more likely to not be taking any antithrombotics prior to admission (34% vs 24%, p=0.007) or have subtherapeutic INR on admission if taking warfarin (83% vs 63%; p = 0.046). Among the AF-EVT patients, 44% were taking AC, and only 31% were adequately anticoagulated. Only 8% of AF-EVT patients who were not on pre-admission AC had a clear contraindication, and 94% were ultimately discharged on AC.ConclusionsLack of antithrombotic therapy in AF patients disproportionately contributes to strokes requiring EVT. A small minority of AF patients have contraindications to AC, so adequate anticoagulation can prevent a remarkable number of strokes requiring EVT.     

Outcomes in patients with ischaemic stroke undergoing endovascular thrombectomy: Impact of atrial fibrillation

ObjectivesEndovascular thrombectomy (EVT) is associated with good clinical outcomes in ischaemic stroke, but the risk of intracerebral haemorrhage (ICH) and mortality remains common following ischaemic stroke. The effect of concomitant atrial fibrillation (AF) on clinical outcomes following acute ischaemic stroke in patients receiving EVT remains unclear. The aim is to investigate associations between AF and intracerebral haemorrhage and all-cause mortality at 90 days in patients with ischaemic stroke undergoing EVT.Materials and MethodsA retrospective cohort was conducted using TriNetX, a global health research network. The network was searched for people aged ≥18 years with ischaemic stroke, EVT and AF recorded in electronic medical records between 01/09/2018 and 01/09/2021. These patients were compared to controls with ischaemic stroke, EVT and no AF. Propensity score matching for age, sex, race, comorbidities, National Institutes of Health Stroke Scale (NIHSS) scores, and prior use of anticoagulation was used to balance the cohorts with and without AF.ResultsIn total 3,106 patients were identified with history of ischaemic stroke treated by EVT. After propensity-score matching, 832 patients (mean age 68 ± 13; 47% female) with ischaemic stroke, EVT and AF, were compared to 832 patients (mean age 67 ± 12; 47% female) with ischaemic stroke, EVT and no history of AF. In the cohort with AF, 11.5% (n = 96) experienced ICH within 90 days following EVT, compared with 12.3% (n = 103) in patients without AF (Odds Ratio (OR) 0.92, 95% confidence interval (CI) 0.68-1.24; p = 0.59). In the patients with AF, mortality within 90 days following EVT was 18.7% (n = 156), compared with 22.5% in patients without AF (n = 187) (OR 0.79, 95% CI 0.63-1.01; p = 0.06).ConclusionIn patients with ischaemic stroke undergoing EVT, AF was not significantly associated with intracerebral haemorrhage or all‐cause mortality at 90‐day follow‐up.     

Outcomes of Thai patients with acute ischemic stroke after intravenous thrombolysis

The purpose of this study was to assess outcomes in Thai patients after treatment with intravenous recombinant tissue plasminogen activator (rtPA) and to determine the factors associated with good outcome and death.MethodsPatients with acute ischemic stroke who were treated with intravenous rtPA at Thammasat University Hospital between June 2007 and April 2010 were included. The measured outcome variables were good outcome (mRS 0,1) and death at 3 months. Stepwise multivariable analyses were performed by including the prespecified factors that were associated with the measured outcome variables in the univariate analysis.ResultsThe sample size was 197 patients. At 3 months, 93 patients (47%) had good outcomes while 23 patients (12%) died within the same period. Severe stroke (OR 0.19, 95% CI 0.08–0.44, p-value < 0.0001) and history of hypertension (OR 0.39, 95% CI 0.16–0.93, p-value = 0.033) were independently related to bad outcome at 3 months, while receiving intravenous nicardipine (OR 2.76, 95% CI 1.09–6.94, p-value = 0.032) was associated with good outcome. Severe stroke (OR 5.89, 95% CI 1.29–26.85, p-value = 0.022) and pretreatment high blood glucose levels (OR 8.06, 95% CI 1.21–53.62, p-value = 0.031) each were independently associated with patient death.ConclusionsStandard-dose intravenous rtPA in a cohort of Thai patients led to better clinical outcomes and comparable death rates when compared to other Asian cohorts receiving intravenous rtPA. Several factors were independently associated with patient outcomes at 3 months.     

Number of stentriever passes and outcome after thrombectomy in stroke

Background and purposesStroke secondary to emergent large vessel occlusions (ELVO) involving the anterior circulation can be treated with intravenous tissue plasminogen activator (IV-tPA) or thrombectomy. Data regarding the influence of the number of stentriever passes needed for vessel recanalization on outcome is lacking.Patients and methodsWe prospectively accrued data on consecutive patients with ELVO that were treated with thrombectomy. Procedural details including the number of stentriever passes needed to achieve vessel recanalization and clot length were collected. Functional outcome was determined with the modified Rankin Scale (mRS) at 90 days post stroke with mRS ≤ 2 considered favorable outcome. Data on demographics, risk factors, stroke severity, survival, and occurrence of symptomatic intracranial hemorrhage (sICH) was also collected.ResultsOn univariate analysis more than one pass needed to achieve recanalization impacted survival and functional outcome after 90 days as did age, stroke severity and collateral and reperfusion status. On multivariate logistic regression the number of passes needed to achieve revascularization (OR: 10.0, 95% CI: 2.28–43.94, P = 0.002), age (OR: 0.90, 95% CI: 0.84–0.96, P = 0.001) and collateral status (OR: 7.90, 95% CI: 1.87–33.35, P = 0.005) remained significant modifiers for favorable outcome. On logistic regression the only variable associated with the need to perform more than a single stentriever pass was time from symptom onset to target vessel recanalization (OR: 1.007, 95% CI: 1.002–1.012).ConclusionsThe number of passes needed to achieve target vessel recanalization modifies outcome after thrombectomy and successful recanalization after a single pass is associated with favorable outcome.