Adherence to oral anticoagulation in ischemic stroke patients with atrial fibrillation

Abstract Background The optimal timing for starting anticoagulation after an acute ischemic stroke related to non-valvular atrial fibrillation (AF) remains a challenge, especially in patients treated with systemic thrombolysis or mechanical thrombectomy. Purpose We aimed to assess the rates of early recurrence and major bleeding in patients with acute ischemic stroke and AF treated with thrombolytic therapy and/or thrombectomy who received oral anticoagulants for secondary prevention. Methods We combined the dataset of the RAF and the RAF-NOACs studies, which were prospective observational studies carried out from January 2012 to March 2014 and April 2014 to June 2016, respectively. We included consecutive patients with acute ischemic stroke and AF treated with either vitamin K antagonists (VKAs) or new oral anticoagulants (NOACs). Primary outcome was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding within 90 days from the inclusion. Results A total of 2,159 patients were included in the RAF and RAF-NOACs trials, of which 564 patients (26%) were treated with urgent reperfusion therapy. After acute stroke, 505 (90%) patients treated with reperfusion and 1,287 out of the 1,595 (81%) patients not treated with reperfusion started oral anticoagulation. Timing of starting oral anticoagulation was similar in reperfusion-treated and untreated patients (13.5±23.3 vs 12.3±18.3 days, respectively, p=0.287). At 90 days, the composite rate of recurrence and major bleeding occurred in 37 (7%) of patients treated with reperfusion treatment and in 139 (9%) of untreated patients (p=0.127). Twenty-four (4%) reperfusion-treated patients and 82 (5%) untreated patients had early recurrence while major bleeding occurred in 13 (2%) treated and in 64 (4%) untreated patients, respectively. Seven patients in the untreated group experienced both an ischemic and hemorrhagic event. Figure 1 shows the risk of early recurrence and major bleeding over time in patients treated and not treated with reperfusion treatments. The use of NOACs was associated with a favorable rate of the primary outcome compared to VKAs (Odd ratio 0.4, 95% Confidence Interval 0.3–0.7). Conclusions Reperfusion treatment did not influence the risk of early recurrence and major bleeding in patients with AF-related acute ischemic stroke who started anticoagulant treatment. Figure 1 Funding Acknowledgement Type of funding source: None

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Resting Heart Rate and In-Hospital Mortality in Acute Ischemic Stroke Patients With and Without Atrial Fibrillation

Circulation Journal ◽

10.1253/circj.cj-19-0946 ◽

2020 ◽

Vol 84 (4) ◽

pp. 656-661

Author(s):

Qiao Han ◽

Chunyuan Zhang ◽

Shoujiang You ◽

Danni Zheng ◽

Chongke Zhong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Resting Heart Rate ◽

Stroke Patients

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Blood biomarkers to detect new-onset atrial fibrillation and cardioembolism in ischemic stroke patients

Heart Rhythm ◽

10.1016/j.hrthm.2021.01.032 ◽

2021 ◽

Author(s):

Dorin Harpaz ◽

Ram Bajpai ◽

Geelyn J.L. Ng ◽

Michael Soljak ◽

Robert S. Marks ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Blood Biomarkers ◽

Stroke Patients ◽

Onset Atrial Fibrillation ◽

New Onset

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Oral Anticoagulation and Adverse Outcomes after Ischemic Stroke in Heart Failure Patients without Atrial Fibrillation

Journal of Cardiac Failure ◽

10.1016/j.cardfail.2021.02.017 ◽

2021 ◽

Author(s):

Omar Saeed ◽

Shuaiqi Zhang ◽

Snehal R. Patel ◽

Ulrich P. Jorde ◽

Mario J. Garcia ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Oral Anticoagulation ◽

Adverse Outcomes ◽

Heart Failure Patients

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Abstract P683: Thrombin Generation in Plasma of Stroke Patients With Atrial Fibrillation

Stroke ◽

10.1161/str.52.suppl_1.p683 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Sarina Falcione ◽

Gina Sykes ◽

Joseph Kamtchum Tatuene ◽

Danielle Munsterman ◽

Twinkle Joy ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Thrombin Generation ◽

Thrombus Formation ◽

Lag Time ◽

Thrombin Time ◽

Stroke Patients ◽

Time To Peak ◽

Generation Capacity

Background and Purpose: Thrombus formation is central to pathophysiology of stroke in patients with atrial fibrillation. Whether factors in plasma contribute to thrombus generation in patients with atrial fibrillation remains unclear. In this study we sought to determine whether plasma contributes to thrombin generation in patients with atrial fibrillation. Methods: There were 78 acute ischemic strokes with atrial fibrillation and 37 non-stroke controls. Plasma thrombin generation was measured by thrombin generation assay, resulting lag time, peak thrombin, time to peak and area under the curve was assessed. Thrombin generation capacity was compared in stroke patients with atrial fibrillation to non-stroke controls. The relationship to anticoagulation was assessed. In vitro, the effect of anticoagulation on plasma thrombin generation was determined. Results: Thrombin generation capacity was increased (shorter lag time and time to peak) in ischemic stroke patients with atrial fibrillation compared to non-stroke atrial-fibrillation controls (p<0.05 and p<0.01, respectively). Anticoagulation decreased plasma induced thrombin generation. Ischemic stroke patients with atrial fibrillation treated with anticoagulation (DOAC or warfarin) had lower plasma induced thrombin generation compared to atrial-fibrillation patients not on anticoagulation (p<0.05). Thrombin generation by plasma could be further reduced by DOAC in an in-vitro assay. Conclusions: Stroke patients with atrial fibrillation have a higher plasma induced thrombin generation compared to atrial fibrillation controls. Factors in plasma such as leukocyte derived tissue factor likely contribute to thrombus formation in patients with atrial fibrillation. As such, components in plasma may represent new targets to reduce thrombus formation and stroke risk in patients with atrial fibrillation.

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Abstract 176: Long Term Mortality in Acute Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation According to Location and Burden of Cerebral Microbleeds

Stroke ◽

10.1161/str.45.suppl_1.176 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Tae-Jin Song ◽

Jinkwon Kim ◽

Dongbeom Song ◽

Yong-Jae Kim ◽

Hyo Suk Nam ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hemorrhagic Stroke ◽

Independent Predictor ◽

Stroke Patients ◽

Risk Of Death ◽

Long Term Mortality

Background: Cerebral microbleeds (CMBs) were predictive of mortality in elderly and considered as a putative marker for risk of intracranial hemorrhage. Stroke patients with non valvular atrial fibrillation (NVAF) require anticoagulation, which increases the risk of hemorrhages. We investigated association of CMBs with the long term mortality in acute ischemic stroke patients with NVAF. Methods: During 6 years , consecutive ischemic stroke patients who had NVAF and who had undergone brain MRI with a gradient-recalled echo sequence were enrolled. Long-term mortality and causes of death were identified using data from Korean National Statistical Office. Survival analysis was performed whether the presence, number and location of CMBs were related with all causes, cardiovascular, and cerebrovascular mortality during follow-up. Results: Total 506 patients were enrolled during the study period and were followed up for median 2.5 years. CMBs were found in 30.8% of patients (156/506). Oral anticoagulation with warfarin was prescribed at discharge in 477 (82.7%) patients. During follow up, 177 (35%) patients died and cerebrovascular death was noted in 93 patients (81 ischemic stroke and 12 hemorrhagic stroke). After adjusting age, sex and significant variables in univariate analysis (p<0.1), multiple CMBs (≥5) were the independent predictor for all-cause, cardiovascular and ischemic stroke mortalities. The strictly lobar CMBs were associated with hemorrhagic stroke mortality in multivariate Cox regression analysis (HR 4.776, p=0.032) (Figure 1). Conclusions: Multiple CMBs were the independent predictor for the long term mortality in stroke patients with NVAF. Among them, patients with strictly lobar CMBs had a high risk of death due to hemorrhagic stroke. Our findings suggest that detection of CMBs in stroke patients with NVAF are of clinical relevance for predicting long term outcome and that particular concern is necessary in those with strictly lobar CMBs for their increased risk of death due to hemorrhagic stroke. Figure 1.

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Abstract WP226: Short Lasting Runs (<30 sec) of Atrial Fibrillation are More Commonly Observed in Ischemic Stroke Patients in Comparison to Controls

Stroke ◽

10.1161/str.47.suppl_1.wp226 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Ethem Murat Arsava ◽

Ezgi Yetim ◽

Ugur Canpolat ◽

Necla Ozer ◽

Kudret Aytemir ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Multivariate Analyses ◽

Holter Monitoring ◽

Female Gender ◽

Prior History ◽

Consecutive Series ◽

Stroke Patients ◽

Cross Sectional ◽

History Of

Background: The role of short-lasting (<30 sec) runs of atrial fibrillation (AF) in ischemic stroke pathophysiology is currently unknown. Although these non-sustained attacks are considered as a risk factor for future development of longer lasting, classical AF episodes, prior research has highlighted that associated clinical stroke features are not entirely similar between these two types of arrhythmias. In this study we determined the prevalence of short-lasting AF in stroke-free controls and compared it to a consecutive series of ischemic stroke patients. Methods: A total 235 controls, without any prior history stroke or AF, were evaluated with ECG and 24-hour Holter monitoring for the presence of <30-sec or ≥30-sec lasting AF episodes. The results were compared to a consecutive series of ischemic stroke patients without prior history of AF (n=456). Univariate and multivariate analyses were performed to determine demographic and cardiovascular factors related to <30-sec lasting AF and its association with ischemic stroke. Results: Expectedly, the frequency of newly diagnosed ≥30-sec lasting AF, detected either on ECG or Holter monitoring, was significantly higher in patients with ischemic stroke (18% vs. 2%; p<0.01). Non-sustained AF was positively related to old age (p<0.01), female gender (p=0.01) and hypertension (p<0.01) in univariate analyses. In multivariate analyses, after adjustment for demographic and cardiovascular risk factors, presence of non-sustained AF was significantly higher among both cryptogenic (OR 1.78; 95% CI 1.02-3.10) and non-cryptogenic (OR 1.84; 95% CI 1.15-2.94) stroke patients with respect to controls. Conclusion: Our study shows a higher prevalence of non-sustained AF episodes in ischemic stroke patients in comparison to controls. Whether this cross-sectional association translates into causality in terms of stroke pathophysiology will be the subject of future studies.

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