scholarly journals Early Dabigatran Treatment After Transient Ischemic Attack and Minor Ischemic Stroke Does Not Result in Hemorrhagic Transformation

2020 ◽  
Vol 47 (5) ◽  
pp. 604-611
Author(s):  
Anas Alrohimi ◽  
Kelvin Ng ◽  
Dar Dowlatshahi ◽  
Brian Buck ◽  
Grant Stotts ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Infarct Volume ◽  
Hemorrhagic Transformation ◽  
Minor Stroke ◽  
Optimal Timing ◽  
Minor Ischemic Stroke ◽  
Pre Treatment ◽  
Ischemic Attack ◽  
Ischemic Events

ABSTRACT:Objectives:The optimal timing of anticoagulation after ischemic stroke in atrial fibrillation (AF) patients is unknown. Our aim was to demonstrate the feasibility and safety of initiating dabigatran therapy within 14 days of transient ischemic attack (TIA) or minor stroke in AF patients.Patients and Methods:A prospective, multi-center registry (NCT02415855) in patients with AF treated with dabigatran within 14 days of acute ischemic stroke/TIA (National Institutes of Health Stroke Scale (NIHSS) ≤ 3) onset. Baseline and follow-up computed tomography (CT) scans were assessed for hemorrhagic transformation (HT) and graded by using European Cooperative Acute Stroke Study criteria.Results:One hundred and one patients, with a mean age of 72.4 ± 11.5 years, were enrolled. Median infarct volume was 0 ml. Median time from index event onset to dabigatran initiation was 2 days, and median baseline NIHSS was 1. Pre-treatment HT was present in seven patients. No patients developed symptomatic HT. On the day 7 CT scan, HT was present in six patients (one progressing from baseline hemorrhagic infarction type 1). Infarct volume was a predictor of incident HT (odds ratio = 1.063 [1.020–1.107], p < 0.003). All six (100%) patients with new/progressive HT were functionally independent (modified Rankin Scale (mRS) = 0–2) at 30 days, which was similar to those without HT (90%, p = 0.422). Recurrent ischemic events occurred within 30 days in four patients, two of which were associated with severe disability and death (mRS 5 and 6, respectively).Conclusion:Early dabigatran treatment did not precipitate symptomatic HT after minor stroke. Asymptomatic HT was associated with larger baseline infarct volumes. Early recurrent ischemic events may be clinically more important.

scholarly journals Dabigatran following acute transient ischemic attack and minor stroke II (DATAS II)

2017 ◽  
Vol 12 (8) ◽  
pp. 910-914 ◽  
Author(s):  
Kuan H Ng ◽  
Mukul Sharma ◽  
Oscar Benavente ◽  
Laura Gioia ◽  
Thalia S Field ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Ischemic Stroke ◽  
Magnetic Resonance ◽  
Transient Ischemic Attack ◽  
Hemorrhagic Transformation ◽  
Phase Iii ◽  
Minor Stroke ◽  
Resonance Imaging ◽  
Repeat Magnetic Resonance Imaging ◽  
Ischemic Attack

Rationale Patients with transient ischemic attack or minor stroke are at high risk of early recurrent cerebrovascular events. Anticoagulation with heparin or warfarin acutely after ischemic stroke is at least as efficacious as aspirin for preventing recurrent events but is associated with an increased risk of clinical worsening due to hemorrhagic transformation. Aim and hypothesis We aim to demonstrate the safety of early anticoagulation with dabigatran, an oral direct thrombin inhibitor, in acute cerebrovascular syndrome patients. The primary hypothesis is that symptomatic hemorrhagic transformation rates in dabigatran and aspirin-treated patients will be similar. Sample size estimates At least 136 participants in two groups required to demonstrate an absolute between-group difference in the rate of hemorrhagic transformation of 5.6% with 80% power, assuming alpha = 5%. Methods and design A randomized, multicenter open-label clinical trial (NCT02295826). Three-hundred participants with a transient ischemic attack/ischemic stroke (National Institutes of Health Stroke Scale ≤ 9) will undergo magnetic resonance imaging within 72 h of symptom onset and will be randomized to aspirin 81 mg daily or dabigatran 150 mg twice daily for 30 days. Participants undergo repeat magnetic resonance imaging at 30 days and clinical assessment to 90 days. Study outcomes The primary outcome is the symptomatic hemorrhagic transformation rate. Secondary outcomes include recurrent stroke and new ischemic lesions on repeat magnetic resonance imaging. Discussion This study will determine the safety of early anticoagulation with dabigatran in patients with acute transient ischemic attack/ischemic stroke and will inform the design of a phase III randomized trial aimed at demonstrating reduced recurrent early ischemic events after acute transient ischemic attack/stroke.

scholarly journals Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke

Circulation ◽  
2019 ◽  
Vol 140 (8) ◽  
pp. 658-664 ◽  
Author(s):  
S. Claiborne Johnston ◽  
Jordan J. Elm ◽  
J. Donald Easton ◽  
Mary Farrant ◽  
William G. Barsan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Transient Ischemic Attack ◽  
Time Course ◽  
Hazard Ratio ◽  
Major Hemorrhage ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack ◽  
Ischemic Events ◽  
Benefit And Risk

Background: In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke [POINT] Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone. Methods: In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models. Results: Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0–21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50–0.85; P =0.0015, in comparison to 22–90 days hazard ratio, 1.38; 95% CI, 0.81–2.35; P =0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset. Conclusions: The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00991029.

Abstract P713: Early Apixaban Therapy After Ischemic Stroke in Patients With Atrial Fibrillation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Anas Alrohimi ◽  
Brian H Buck ◽  
Glen Jickling ◽  
Ashfaq Shuaib ◽  
Sibi Thirunavukkarasu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Infarct Volume ◽  
Hemorrhagic Transformation ◽  
Performance Criteria ◽  
Optimal Timing ◽  
Open Label ◽  
Stroke Study ◽  
Ischemic Events

Background: The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. Patients and methods: A prospective, open label study (NCT04435418) of patients with AF treated with apixaban within 14 days of ischemic stroke/TIA onset was conducted. Baseline and follow-up CT scans were assessed for hemorrhagic transformation (HT) and graded using European Cooperative Acute Stroke Study (ECASS) criteria. The primary endpoint was symptomatic HT. Incident HT rates were assessed as Objective Performance Criteria. Results: One-hundred AF stroke patients, with a mean age of 79±11 years were enrolled. Median infarct volume was 4 (0.5-10.75) ml. Median time from index event onset to apixaban initiation was 2 (1-6) days, and median baseline NIHSS was 4 (1-9). Asymptomatic HT on baseline imaging was present in 15 patients. Infarct volume (OR= 1.1, [1.02-1.12], P <0.0001) and NIHSS (OR= 1.11, [1.03-1.20], P =0.007) were both associated with baseline HT. No patients developed symptomatic HT or systemic hemorrhage. Incident asymptomatic HT was seen on follow-up CT scan in 3 patients. Patients with incident HT were functionally independent (mRS=0-2) at 90 days. Recurrent ischemic events occurred within 90 days in 13 patients, 4 of which were associated with severe disability (mRS 3-5) and 4 with death. Discussion: Early apixaban treatment did not precipitate symptomatic HT after stroke. All HT was asymptomatic identified on imaging. Recurrent ischemic events were common and clinically symptomatic. Conclusions: Symptomatic HT rates are likely to be low in randomized trials of DOAC initiation post-stroke. Recurrent ischemic stroke may be the major clinical outcome.

scholarly journals Predictors of Hospitalization in Patients With Transient Ischemic Attack or Minor Ischemic Stroke

2016 ◽  
Vol 43 (4) ◽  
pp. 523-528 ◽  
Author(s):  
Moira K. Kapral ◽  
Ruth Hall ◽  
Jiming Fang ◽  
Peter C. Austin ◽  
Frank L. Silver ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Population Based ◽  
Minor Stroke ◽  
Local Health ◽  
Stroke Registry ◽  
Persistent Symptoms ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

AbstractBackground: Transient ischemic attack (TIA) and minor stroke are associated with a substantial risk of subsequent stroke; however, there is uncertainty about whether such patients require admission to hospital for their initial management. We used data from a clinical stroke registry to determine the frequency and predictors of hospitalization for TIA or minor stroke across the province of Ontario, Canada. Methods: The Ontario Stroke Registry collects information on a population-based sample of all patients seen in the emergency department with acute stroke or TIA in Ontario. We identified patients with minor ischemic stroke or TIA included in the registry between April 1, 2008, and March 31, 2011, and used multivariable analyses to evaluate predictors of hospitalization. Results: Our study sample included 8540 patients with minor ischemic stroke or TIA, 47.2% of whom were admitted to hospital, with a range of 37.6% to 70.3% across Ontario’s 14 local health integration network regions. Key predictors of admission were preadmission disability, vascular risk factors, presentation with weakness, speech disturbance or prolonged/persistent symptoms, arrival by ambulance, and presentation on a weekend or during periods of emergency department overcrowding. Conclusions: More than one-half of patients with minor stroke or TIA were not admitted to the hospital, and there were wide regional variations in admission patterns. Additional work is needed to provide guidance to health care workers around when to admit such patients and to determine whether discharged patients are receiving appropriate follow-up care.

scholarly journals Newly Diagnosed Atrial Fibrillation After Transient Ischemic Attack Versus Minor Ischemic Stroke in the POINT Trial

2021 ◽  
Vol 10 (6) ◽  
Author(s):  
Hooman Kamel ◽  
Mary Farrant ◽  
J. Donald Easton ◽  
Luciano A. Sposato ◽  
Jordan J. Elm ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Minor Stroke ◽  
Newly Diagnosed ◽  
Event Type ◽  
Primary Analysis ◽  
Index Event ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

Background Atrial fibrillation/flutter (AF) after transient ischemic attack (TIA) has not been well studied. We compared the likelihood of new AF diagnosis after ischemic stroke versus TIA. Methods and Results The POINT (Platelet‐Oriented Inhibition in New TIA and Minor Ischemic Stroke) trial enrolled adults within 12 hours of minor ischemic stroke or high‐risk TIA. Our exposure was index event type (ischemic stroke versus TIA). The primary analysis used the original trial definition of TIA (resolution of symptoms/signs). In secondary analyses, TIA cases with infarction on neuroimaging were reclassified as strokes. Our primary outcome was a new AF diagnosis, ascertained from adverse event and treatment interruption/discontinuation reports. We calculated C‐statistics for variables associated with newly diagnosed AF. We used Kaplan‐Meier survival statistics and Cox models adjusted for demographics and vascular risk factors. Excluding 49 subjects with baseline AF, 2746 patients had index stroke and 2086 patients had index TIA. During the 90‐day follow‐up, 106 patients had newly diagnosed AF. Cumulative risks of AF were 2.7% (95% CI, 2.1%–3.4%) after stroke and 2.0% (95% CI, 1.5%–2.7%) after TIA ( P =0.15). After reclassifying index events by neuroimaging, cumulative AF risk was higher after stroke (2.7%; 95% CI, 2.2%–3.4%) than TIA (1.8%; 95% CI, 1.3%–2.5%) ( P =0.04). Index event type had negligible predictive utility (C‐statistic, 0.54). Conclusions Among patients with cerebral ischemia, the distinction between TIA versus minor stroke did not stratify the risk of subsequent AF diagnosis, implying that patients with TIA should undergo similar heart‐rhythm monitoring strategies as patients with ischemic stroke.

scholarly journals Impact of Platelet Endothelial Aggregation Receptor-1 Genotypes on Long-Term Cerebrovascular Outcomes in Patients With Minor Stroke or Transient Ischemic Attack

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiao-Guang Zhang ◽  
Jing-Yu Gu ◽  
Qiang-Qiang Fu ◽  
Shi-Wu Chen ◽  
Jie Xue ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Bleeding Risk ◽  
Chinese Patients ◽  
Minor Stroke ◽  
Bleeding Events ◽  
Minor Ischemic Stroke ◽  
Cox Proportional Hazard Regression ◽  
Ischemic Attack

Background: Platelet endothelial aggregation receptor-1 (PEAR1) rs12041331 has been reported to affect agonist-stimulated platelet aggregation, but it remains unclear whether this variant plays a role in recurrent stroke. Here we assess the clinical relevance of PEAR1 rs12041331 in acute minor ischemic stroke (AMIS) and transient ischemic attack (TIA) Chinese patients treated with dual antiplatelet therapy (DAPT).Methods: We recruited 273 consecutive minor stroke and TIA patients, and Cox proportional hazard regression was used to model the relationship between PEAR1 rs12041331 and thrombotic and bleeding events.Results: Genotyping for PEAR1 rs12041331 showed 49 (18.0%) AA homozygotes, 129 (47.3%) GA heterozygotes, and 95 (34.7%) GG homozygotes. No association was observed between PEAR1 rs12041331 genotype and stroke or composite clinical vascular event rates (ischemic stroke, hemorrhagic stroke, TIA, myocardial infarction, or vascular death) or bleeding events regardless if individuals carried one or two copies of the A allele. Our results suggested that rs12041331 genetic polymorphism was not an important contributor to clinical events in AMIS and TIA patients in the setting of secondary prevention.Conclusions: Our data do provide robust evidence that genetic variation in PEAR1 rs12041331 do not contribute to atherothrombotic or bleeding risk in minor stroke and TIA patients treated with DAPT.

Hemostatic Activity in Patients with a Transient Ischemic Attack or Minor Ischemic Stroke with or without Chronic Non-Valvular Atrial Fibrillation

1993 ◽  
Vol 3 (6) ◽  
pp. 350-356
Author(s):  
Gheorghe A. Pop ◽  
Han J. Meeder ◽  
Wynsen van Oudenaarden ◽  
Jeannette C. van Latum ◽  
Wim Verweij ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Minor Ischemic Stroke ◽  
Hemostatic Activity ◽  
Ischemic Attack

Abstract TP438: Japanese versus Non-Japanese Patients With Transient Ischemic Attack or Minor Stroke: Five-Year Risk of Stroke and Vascular Events

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shinichiro Uchiyama ◽  
Takao Hoshino ◽  
Hugo Charles ◽  
Kenji Kamiyama ◽  
Taizen Nakase ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Transient Ischemic Attack ◽  
Japanese Patients ◽  
Minor Stroke ◽  
Stroke Recurrence ◽  
Large Artery ◽  
Vascular Events ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

Background: We have reported 5-year risk of stroke and vascular events after a transient ischemic attack (TIA) or minor ischemic stroke in patients enrolled into the TIAregistry.org, which was an international multicenter-cooperative, prospective registry (N Engl J Med 2018;378:2182-90). We conducted subanalysis on the 5-year follow-up data of Japanese patients in comparison with non-Japanese patients. Methods: The patients were classified into two groups on ethnicity, Japanese (n=345) and non-Japanese (n=3502), and their 5-year event rates were compared. We also determined predictors of five-year stroke in both groups. Results: Death from vascular cause (0.9% vs 2.7%, HR 0.28, 95% CI 0.09-0.89, p=0.031) and death from any cause (7.8% vs 9.9%, HR 0.67, 95% CI 0.45-0.99, p=0.045) were fewer in Japanese patients than in non-Japanese patients, while stroke (13.9% vs 7.2%, HR 1.78, 95% CI 1.31-2.43, p<0.001) and intracranial hemorrhage (3.2% vs 0.8%, HR 3.61. 95% CI 1.78-7.30, p<0.001) were more common in Japanese than non-Japanese patients during five-year follow-up period. Caplan-Meyer curves at five-years showed that the rates of stroke was also significantly higher in Japanese than non-Japanese patients (log-rank test, p=0.001). Predictors for stroke recurrence at five years were large artery atherosclerosis (HR 1.81, 95% CI 1.31-2.52, p<0.001), cardioembolism (HR 1.71, 95% CI 1.18-2.47, p=0.004), multiple acute infarction (HR 1.77, 95% CI 1.27-2.45, p<0.001) and ABCD 2 score 6 or 7 (HR 1.96, 95% CI 1.38-2.78, p<0.001) in non-Japanese patients, although only large artery atherosclerosis (HR 3.28, 95% CI 1.13-9.54, p=0.029) was a predictor for stroke recurrence in Japanese patients. Conclusions: Recurrence of stroke and intracranial hemorrhage were more prevalent in Japanese than non-Japanese patients. Large artery atherosclerosis was a predictor for stroke recurrence not only in non-Japanese patients but also in Japanese patients.

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