Reduced Doses of Direct Oral Anticoagulants in Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation

Background: The choice of standard or reduced doses of direct oral anticoagulants (DOACs) depends on patients’ age, body weight, and renal function based on package instructions. Our aim was to conduct a simulation of DOAC dose using patients’ data obtained on admission. Methods: This retrospective study included 314 ischemic stroke patients with nonvalvular atrial fibrillation admitted to our hospital between September 2014 and February 2018. Data on age, body weight, creatinine, and creatinine clearance were collected for each subject, and simulation was conducted for the dose of each DOAC. Results: The mean age of 314 subjects was 77.2 years; those aged 75 years or older accounted for 61.5% (193 patients). It was suggested that a standard dose of rivaroxaban could be used in 67.5% of patients and that of apixaban in 65.9%. By contrast, a standard dose of dabigatran could be used in only 16.9% of patients and that of edoxaban in only 32.5%. The simulation analysis for patients aged 75 years or older showed that a standard dose of rivaroxaban could be used in 54.9% of patients and that of apixaban in 44.6%, while that of edoxaban could be used in only 19.7% of patients. Conclusions: When DOACs are prescribed for secondary prevention of cerebral infarction in patients with nonvalvular atrial fibrillation, the rate of standard or reduced dose varies depending on the kind of DOAC. Further analysis is required to clarify whether a standard dose of one DOAC or reduced dose of another DOAC yields the best result for each patient.     

Transesophageal Echocardiographic Findings Are Independent and Relevant Predictors of Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation

Background and Purpose

Not only clinical factors, including the CHADS₂ score, but also echocardiographic findings have been reported to be useful for predicting the risk of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it remains to be determined which of these factors might be more relevant for evaluation of the risk of stroke in each patient.

Methods

In 490 patients with NVAF who underwent transesophageal echocardiography (TEE), we examined the long-term incidence of ischemic stroke events (mean follow-up time, 5.7±3.3 years). For each patient, the predictive values of gender, the CHADS₂ risk factors (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, history of cerebral ischemia), the CHADS₂ score, and the findings on echocardiography, including TEE risk markers, were assessed.

Results

The ischemic stroke rate was significantly correlated with the CHADS₂ score (p<0.05). According to the results of univariate analyses, age ≥75 years, history of cerebral ischemia, CHADS₂ score ≥2, and presence of TEE risk were significantly correlated with the incidence of ischemic stroke. Cox proportional hazards regression analyses identified age ≥75 years and presence of TEE risk as significant predictors of subsequent ischemic stroke events in patients with NVAF. As compared with that in persons below 75 years of age without TEE risk, the ischemic stroke rate was significantly higher in persons who were ≥75 years of age with TEE risk (4.3 vs. 0.56%/year, adjusted hazard ratio=8.94, p<0.001).

Conclusions

TEE findings might be more relevant predictors of ischemic stroke than the CHADS₂ score in patients with NVAF. The stroke risk was more than 8-fold higher in patients aged ≥75 years with TEE risk.     

心房颤动合并急性缺血性脑卒中的溶栓及抗凝治疗研究进展

急性缺血性脑卒中是常见病、多发病。心房颤动(房颤)是临床上常见的心律失常,尤以非瓣膜性房颤为著。房颤合并急性缺血性脑卒中的患者临床常见,且病情重、出血转化率高、复发率高,给治疗带来一定的难度。重组组织型纤溶酶原激活剂是目前治疗急性缺血性脑卒中最有效的药物,可减少急性缺血性脑卒中患者的致残率;口服抗凝药可减少房颤相关急性缺血性脑卒中的复发;抗血小板治疗对房颤合并急性缺血性脑卒中患者也有一定的二级预防作用。鉴于房颤合并急性缺血性脑卒中所特有的临床特征,选择适宜的药物治疗至关重要。     

新型口服抗凝药预防非瓣膜性心房颤动相关性脑卒中的应用进展

非瓣膜性心房颤动(房颤)相关性脑卒中的临床后果严重,是房颤致残、致死的最主要原因。口服华法林是预防房颤患者发生脑卒中事件的有效措施,但华法林的抗凝治疗窗窄,显效慢,疗效易受食物和药物的影响,故需反复检测凝血功能并根据国际标准化比值调整使用剂量,从而降低了患者的用药依从性。以凝血酶抑制剂及Ⅹa因子抑制剂为代表的新型口服抗凝剂较华法林能显著降低房颤相关性脑卒中的发病率和出血风险,有望成为房颤患者抗凝治疗的新选择。     

嘉兴地区急性缺血性卒中合并心房颤动患者抗凝治疗现状分析

目的 调查嘉兴地区急性缺血性卒中合并心房颤动患者的抗凝治疗现状。 方法 回顾性分析2016年1月-2020年12月基于CT临床数据采集系统对卒中医疗质量改进的研究登 记库-Ⅱ（computer analysing system to improve stroke management quality evaluation-Ⅱ,CASE-Ⅱ）中的 嘉兴地区卒中中心登记的急性缺血性卒中合并心房颤动住院患者的信息。根据患者出院是否带有抗 凝药物分为出院抗凝组与出院未抗凝组,比较两组患者的基本特征,采用logistic回归分析出院抗凝 药物使用的影响因素;并进一步在既往诊断心房颤动且卒中高危（CHA2DS2-VASc≥2分）患者亚群中分 析抗凝药物使用的影响因素。 结果 共纳入患者2005例,平均年龄77±8岁,男性979例（48.8%）,NIHSS中位评分5（2～13）分。 无抗血栓治疗禁忌证患者1817例,出院时带抗血栓药物比例为83.9%（1525/1817）,其中抗凝药 物比例为41.3%（750/1817）。年龄（OR 0.964,95%CI 0.952～0.976）,基线NIHSS评分（OR 0.935, 95%CI 0.920～0.951）,住院时间（OR 1.045,95%CI 1.025～1.066）,深静脉血栓（OR 2.797, 95%CI 1.472～5.311）,住院期间是否发生任意的颅内出血（OR 0.085,95%CI 0.038～0.188）、消化 道出血（OR 0.503,95%CI 0.257～0.985）、肺炎（OR 0.646,95%CI 0.488～0.856）是急性缺血性卒中 合并心房颤动患者出院接受抗凝治疗与否的独立影响因素。既往诊断心房颤动且卒中高危患者接受 抗凝治疗比例仅为16.0%（153/954）,低龄（OR 0.957,95%CI 0.938～0.975）、低收缩压（OR 0.985, 95%CI 0.977～0.993）、卒中/TIA病史（OR 2.773,95%CI 1.954～3.936）是其接受抗凝治疗的独立保护 因素。 结论 嘉兴地区急性缺血性卒中合并心房颤动患者的抗凝治疗率较低,低龄、低基线NIHSS评分、 长住院时间、合并深静脉血栓的患者更多接受抗凝治疗,住院期间发生颅内出血、消化道出血和肺炎 的患者更少接受抗凝治疗。     

Effectiveness of Nonvitamin K Antagonist Oral Anticoagulants and Warfarin for Preventing Further Cerebral Microbleeds in Acute Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation and At Least One Microbleed: CMB-NOW Multisite Pilot Trial

BackgroundNonvitamin K antagonist oral anticoagulants (NOACs) are considered superior, or at least noninferior, to warfarin in preventing stroke or systemic embolism in patients with nonvalvular atrial fibrillation. Here, we recruited acute ischemic stroke patients with nonvalvular atrial fibrillation and at least one cerebral microbleed (CMB), and evaluated the proportion of patients who had an increased number of CMBs (%) after receiving anticoagulant therapy with NOACs or with warfarin for 12 months.MethodsThis was a multicenter, prospective, observational cohort study at 20 centers, conducted between 2015 and 2017, in which we recruited 85 patients with at least one CMB detected by 1.5T magnetic resonance imaging (T2*WI) at baseline, who received NOACs or warfarin for at least 12 months. We compared the proportions of patients with increased numbers of CMBs in the NOACs and warfarin treatment groups.ResultsThe proportions of patients with increased numbers of CMBs at month 12 of treatment were 28.6% and 66.7% in the NOACs and warfarin groups, respectively. The new CMBs showed no specific regional localization in either group. In the NOACs and warfarin groups, physicians prescribed lower-than-standard dosing in 13.3% and 50% of the cases, respectively. The administration of reduced doses at physicians’ discretion did not appear to alter the incidence of new CMBs.DiscussionThis is the first evidence to suggest efficacy of NOACs for preventing further CMBs in patients with at least one CMB, although no statistical evaluation was carried out.     

心房颤动相关缺血性卒中的研究进展

【摘要】 心房颤动是临床上常见的心律失常,其患病率随着年龄增长而增加。由于无症状性心房颤 动的存在,心房颤动发病率及患病率均不完善。心房颤动因并发缺血性卒中而具有很高的致残率、致 死率。口服抗凝药是目前预防心房颤动血栓栓塞并发症最有效的方法。近年来,随着心房颤动发病 率的日益增长及缺血性卒中病因研究的逐渐细化,伴心房颤动的缺血性卒中相关研究引起了学界的广 泛关注。本文就相关研究热点做一综述。