Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease

2021 ◽  
Author(s):  
Aaron M. Gusdon ◽  
Salia Farrokh ◽  
James C. Grotta
Keyword(s):  
Atrial Fibrillation ◽  
Cardiovascular Disease ◽  
Antithrombotic Therapy ◽  
Antiplatelet Agents ◽  
Left Ventricular ◽  
Optimal Treatment ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Nonbacterial Thrombotic Endocarditis

AbstractPrevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

scholarly journals Atrial Fibrillation in Patients With Left Ventricular Assist Devices

2016 ◽  
Vol 2 (7) ◽  
pp. 793-798 ◽  
Author(s):  
Kathleen T. Hickey ◽  
Hasan Garan ◽  
Donna M. Mancini ◽  
Paolo C. Colombo ◽  
Yoshifumi Naka ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

scholarly journals Safety and Efficacy of Routine Bridging Anticoagulation for Subtherapeutic Anticoagulation in Outpatients with a Left Ventricular Assist Device

2018 ◽  
Author(s):  
David C. Shisler ◽  
Gaurang N. Vaidya ◽  
Lori Muncy ◽  
Rajakrishnan Vijayakrishnan ◽  
Mark S. Slaughter ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Safety And Efficacy ◽  
Left Ventricular Assist ◽  
History Of ◽  
Bridging Anticoagulation

Background Anticoagulation with vitamin K antagonists is vital to prevent pump thrombosis in patients with left ventricular assist devices (LVADs). However, the safety and efficacy of bridging anticoagulation for the routine management of subtherapeutic international normalized ratio (INR) in stable outpatients remains poorly characterized. Methods  In this retrospective study, a total of 60 LVAD outpatients had 110 episodes of subtherapeutic INR noted on routine testing. 34 of these episodes were managed with parenteral bridging anticoagulation and 76 were managed with only an adjusted dose of warfarin. The rates of bleeding and thromboembolic adverse events following these episodes of subtherapeutic INR were measured to evaluate the safety and efficacy of bridging anticoagulation in this population. Results Ischemic cerebrovascular events occurred following 2 bridged episodes compared to 4 non-bridged episodes (6% vs. 5%, p=0.895). Hemolysis occurred following 1 bridged episode compared to 3 non-bridged episodes (3% vs. 4%, p=0.794). Bleeding events occurred after 4 bridged episodes compared to 13 non-bridged episodes (12% vs. 17%, p=0.474). In a subgroup of patients with either a CHA2DS2-VASc score > 3 or a history of atrial fibrillation, thromboembolic events occurred only in those who did not receive bridging anticoagulation although this result was not statistically significant. Conclusions There was no benefit associated with the routine use of bridging anticoagulation in a general population of stable LVAD outpatients with subtherapeutic INR. A trend towards benefit was seen in a subset of patients with a CHA2DS2-VASc score of > 3 or a history of atrial fibrillation.

Abstract TP71: Interruption of Antiplatelet and Anticoagulant Therapy Does Not Increase Risk of Recurrent Stroke in Patients with Left Ventricular Assist Devices

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jenny Peih-Chir Tsai ◽  
Christopher Barrett ◽  
Neil E Schwartz ◽  
Dipanjan Banerjee
Keyword(s):  
Median Time ◽  
Antithrombotic Therapy ◽  
Combined Therapy ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Time To Recurrence ◽  
Cerebrovascular Events ◽  
Left Ventricular Assist

Introduction: Left ventricular-assist devices (LVAD) have increased survival and quality of life of patients with heart failure. Patients with LVAD have increased risks of ischemic and hemorrhagic cerebrovascular events due to device thrombosis and combined use of antiplatelet and anticoagulant agents. The safety of transient interruption of combined antithrombotic therapy after stroke is unknown. Hypothesis: Time to resumption of combined antiplatelet and anticoagulant therapy after stroke is not associated with the incidence of recurrent cerebrovascular event. Methods: We defined the study cohort of patients who received an LVAD using ICD-9 codes. We obtained data for patients with new cerebrovascular events while on a Heartmate-II or Heartware LVAD, and excluded those deceased from the initial event. We divided patient-events into two cohorts based on the index event: ischemic (TIA, stroke) or hemorrhagic (all intracranial hemorrhages, ICH). We used Fisher’s exact test to assess the association between recurrent ischemic event or ICH and time off combined antithrombotic therapy. We pre-specified variables for adjustment in the logistic regression analysis: age, cardiovascular risk factors, LVAD model, indication and endpoint, NIHSS score, INR and LDH levels, and baseline and change in antithrombotic therapy. Results: The study included 48 patient-events between 2011 and 2016: 23 (48%) were ischemic (9 (40%) TIA and 14 (60%) infarcts) and 25 (52%) hemorrhagic. The ischemic event cohort had 9 (39%) recurrences, including 6 (67%) ischemic and 3 (33%) ICH. Median time to recurrence was 118 (IQR 78-388) days. All patients continued on antiplatelet, and maximum time off anticoagulant was 2 (median 0) days. Time off combined therapy was not associated with ischemic (p=0.43) or hemorrhagic recurrence (p=1.00). The ICH cohort had three (12%) recurrences: 1 (33%) ischemic and 2 (67%) hemorrhagic. Median time to recurrence was 158 (IQR 32-586) days. Median time off combined therapy was 7 (0-15) days, and not associated with ischemic (p=0.43) or hemorrhagic recurrence (p=0.83). Conclusion: In patients with LVAD, transient interruption of combined antithrombotic therapy after stroke is not associated with increased risk of recurrent cerebrovascular events.

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