Timing of anticoagulation therapy in patients with acute ischaemic stroke and atrial fibrillation

2016 ◽  
Vol 116 (09) ◽  
pp. 410-416 ◽  
Author(s):  
Maurizio Paciaroni ◽  
Giancarlo Agnelli ◽  
Walter Ageno ◽  
Valeria Caso
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Substantial Reduction ◽  
Anticoagulation Therapy ◽  
Early Recurrence ◽  
Optimal Time ◽  
Optimal Timing ◽  
Stroke Patients ◽  
Haemorrhagic Transformation

SummaryIn patients with acute stroke and atrial fibrillation (AF), the risk of early recurrence has been reported to range between 0.1% and 1.3% per day. Anticoagulants are the most effective therapy for the prevention of recurrent ischaemic stroke in these patients, but randomised clinical trials have failed to produce any evidence supporting the administration of heparin within 48 hours from stroke onset as it has been associated with a non-significant reduction in the recurrence of ischaemic stroke, no substantial reduction in death and disability, and an increase in intracranial bleeding. As early haemorrhagic transformation is a major concern in the acute phase of stroke patients with AF, determining the optimal time to start anticoagulant therapy is essential. This review which focuses on the epidemiology of recurrent ischaemic stroke and haemorrhagic transformation in patients with acute ischaemic stroke and AF, proposes a model for decision making on optimal timing for initiating anticoagulation, based on currently available evidence.

Which Acute Stroke Patients with Atrial Fibrillation are Prescribed Warfarin Therapy? Results from One-Year's Experience in Dundee

2000 ◽  
Vol 45 (4) ◽  
pp. 110-112 ◽  
Author(s):  
J. Craig ◽  
R.S. MacWalter ◽  
B.M. Goudie
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Warfarin Therapy ◽  
Anticoagulation Therapy ◽  
Secondary Prophylaxis ◽  
Stroke Patients ◽  
Clinical Notes ◽  
Recommended Treatment ◽  
Warfarin Sodium

The recommended treatment of ischaemic stroke patients with atrial fibrillation (AF) is anticoagulation therapy with warfarin sodium and if this is contraindicated then aspirin should be used. The management of patients on warfarin therapy can be complicated and there is a risk of intra-cranial haemorrhage in elderly patients. However, these are the patients who stand to gain the most benefit from this treatment and therefore increased use of warfarin for secondary prophylaxis is likely to lead to a lower rate of subsequent admissions and less morbidity. The recommended treatment for these patients has often not been fully instigated in practice. This study was carried out in order to determine whether a group of patients admitted to a teaching hospital with diagnosis of ischaemic stroke and atrial fibrillation received appropriate antithrombotic therapy. Details of patients admitted with acute stroke during 1997 were obtained from the Dundee Stroke Database and information was extracted from the relevant clinical notes. Twenty-five out of 42 patients (60%) were considered eligible for anticoagulation and 14 out of those 25 (56%) were found to be on warfarin either on admission or subsequently. Of patients aged less than 75 years, 8/10 (80%) were on warfarin, whereas only 6/15 (40%) of those aged 75 years and older were being anticoagulated.

scholarly journals Prevalence of Atrial Fibrillation in Patients with Acute Ischaemic Stroke: A Multicentric Cohort Study

2021 ◽  
Author(s):  
Indu Bhana ◽  
Archana Ojha ◽  
Rajendra Kumar Pandey ◽  
Durgvijay Singh ◽  
Mahendra Chourasiya
Keyword(s):  
Atrial Fibrillation ◽  
Cohort Study ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Urban Areas ◽  
Tertiary Care ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Elderly Age ◽  
Female Population

Introduction: India reports high prevalence of stroke, both in rural and urban areas. Secondary prevention is very important in patients with stroke to reduce the morbidity and mortality associated with it. Atrial Fibrillation (AF) is an important risk factor for stroke which can lead to cerebrovascular insult. Aim: To study the prevalence of AF in patients with acute ischaemic stroke and to obtain the association between the parameters such as age, gender, stroke territory and stroke severity by National Institute of Health Stroke Scale (NIHSS). Materials and Methods: In this multicentric cohort study, 150 patients with acute ischaemic stroke (new onset or recurrent) were studied at tertiary care centres located in Indore (Madhya Pradesh), Prayagraj, Moradabad and Lucknow (Uttar Pradesh) from January 2020 to January 2021. Age, gender, stroke territory and stroke severity by NIHSS was recorded and compared between those with and without AF. The Chi-square test was used to assess the association and obtaining significance. Results: Prevalence of AF in patients with stroke was 8% (n=12), which was significantly high in female population (8 out of 12; p=0.025), those with age more than 60 years (10 out of 12; p=0.011), with atrial dilatation (9 out of 12; p=0.124), patients with severe stroke as per NIHSS (7 out of 12; p=0.001) and those with poor outcome (8 out of 12; p=0.012). Conclusion: In the present study, 8% of the stroke patients had AF with stroke. Elderly age, female sex, and large atrial size on Echocardiogram (ECHO) should be intensively investigated for AF in stroke patients.

scholarly journals Rationale and design of the Registry of Acute Stroke Under Novel Oral Anticoagulants-prime (RASUNOA-prime)

2018 ◽  
Vol 4 (2) ◽  
pp. 181-188 ◽  
Author(s):  
Kirsten Haas ◽  
Jan C Purrucker ◽  
Timolaos Rizos ◽  
Peter U Heuschmann ◽  
Roland Veltkamp
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Vitamin K ◽  
Intracerebral Haemorrhage ◽  
Acute Ischaemic Stroke ◽  
Emergency Treatment ◽  
Clinical Course ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Stroke Patients

Background Anticoagulation with vitamin K antagonists and non-vitamin K antagonists oral anticoagulants (NOAC) is effective in stroke prevention in patients with atrial fibrillation. However, anticoagulation also poses a major challenge for emergency treatment of patients suffering ischaemic stroke or intracerebral haemorrhage. Aim The registry RASUNOA-prime is designed to describe current patterns of emergency management, clinical course and outcome of patients with atrial fibrillation experiencing an acute ischaemic stroke or intracerebral haemorrhage under different anticoagulation schemes prior to stroke (NOAC, vitamin K antagonists or no anticoagulation). Methods and design RASUNOA-prime (ClinicalTrials.gov, NCT02533960) is a prospective, investigator-initiated, multicentre, observational cohort study aiming to recruit 3000 patients with acute ischaemic stroke and atrial fibrillation, and 1000 patients with acute intracerebral haemorrhage and atrial fibrillation with different anticoagulation schemes pre-stroke. It is a non-interventional triple-armed study aiming at a balanced inclusion of ischaemic stroke and intracerebral haemorrhage patients according to the different anticoagulation schemes. Patients will be followed up for clinical course, management and outcome up to three months after the event. Findings in ischaemic stroke and intracerebral haemorrhage patients on NOAC will be compared with patients taking vitamin K antagonists or no anticoagulant pre-stroke. Study outcomes Primary endpoint for ischaemic stroke patients: occurrence of symptomatic intracerebral haemorrhage, for intracerebral haemorrhage patients: occurrence of secondary haematoma expansion. Secondary endpoints include assessment of coagulation, use of thrombolysis and/or mechanical thrombectomy, occurrence of complications, implementation of secondary prevention. Summary Describing the current patterns of early management as well as outcome of stroke patients with atrial fibrillation will help guide physicians to develop recommendations for emergency treatment of stroke patients under different anticoagulation schemes.

scholarly journals Early versus late start of direct oral anticoagulants after acute ischaemic stroke linked to atrial fibrillation: an observational study and individual patient data pooled analysis

2021 ◽  
pp. jnnp-2021-327236
Author(s):  
Gian Marco De Marchis ◽  
David J. Seiffge ◽  
Sabine Schaedelin ◽  
Duncan Wilson ◽  
Valeria Caso ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Individual Patient Data ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Pooled Analysis ◽  
Patient Data ◽  
Optimal Timing ◽  
Significant Difference

ObjectiveThe optimal timing to start direct oral anticoagulants (DOACs) after an acute ischaemic stroke (AIS) related to atrial fibrillation (AF) remains unclear. We aimed to compare early (≤5 days of AIS) versus late (>5 days of AIS) DOAC-start.MethodsThis is an individual patient data pooled analysis of eight prospective European and Japanese cohort studies. We included patients with AIS related to non-valvular AF where a DOAC was started within 30 days. Primary endpoints were 30-day rates of recurrent AIS and ICH.ResultsA total of 2550 patients were included. DOACs were started early in 1362 (53%) patients, late in 1188 (47%). During 212 patient-years, 37 patients had a recurrent AIS (1.5%), 16 (43%) before a DOAC was started; 6 patients (0.2%) had an ICH, all after DOAC-start. In the early DOAC-start group, 23 patients (1.7%) suffered from a recurrent AIS, while 2 patients (0.1%) had an ICH. In the late DOAC-start group, 14 patients (1.2%) suffered from a recurrent AIS; 4 patients (0.3%) suffered from ICH. In the propensity score-adjusted comparison of late versus early DOAC-start groups, there was no statistically significant difference in the hazard of recurrent AIS (aHR=1.2, 95% CI 0.5 to 2.9, p=0.69), ICH (aHR=6.0, 95% CI 0.6 to 56.3, p=0.12) or any stroke.ConclusionsOur results do not corroborate concerns that an early DOAC-start might excessively increase the risk of ICH. The sevenfold higher risk of recurrent AIS than ICH suggests that an early DOAC-start might be reasonable, supporting enrolment into randomised trials comparing an early versus late DOAC-start.

scholarly journals Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

2018 ◽  
Vol 4 (1) ◽  
pp. 55-64 ◽  
Author(s):  
Maurizio Paciaroni ◽  
Filippo Angelini ◽  
Giancarlo Agnelli ◽  
Georgios Tsivgoulis ◽  
Karen L Furie ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Paroxysmal Atrial Fibrillation ◽  
Transient Ischaemic Attack ◽  
Early Recurrence ◽  
Index Stroke ◽  
Atrial Enlargement ◽  
History Of ◽  
Ischaemic Attack

Background The relationship between different patterns of atrial fibrillation and early recurrence after an acute ischaemic stroke is unclear. Purpose In a prospective cohort study, we evaluated the rates of early ischaemic recurrence after an acute ischaemic stroke in patients with paroxysmal atrial fibrillation or sustained atrial fibrillation which included persistent and permanent atrial fibrillation. Methods In patients with acute ischaemic stroke, atrial fibrillation was categorised as paroxysmal atrial fibrillation or sustained atrial fibrillation. Ischaemic recurrences were the composite of ischaemic stroke, transient ischaemic attack and symptomatic systemic embolism occurring within 90 days from acute index stroke. Results A total of 2150 patients (1155 females, 53.7%) were enrolled: 930 (43.3%) had paroxysmal atrial fibrillation and 1220 (56.7%) sustained atrial fibrillation. During the 90-day follow-up, 111 ischaemic recurrences were observed in 107 patients: 31 in patients with paroxysmal atrial fibrillation (3.3%) and 76 with sustained atrial fibrillation (6.2%) (hazard ratio (HR) 1.86 (95% CI 1.24–2.81)). Patients with sustained atrial fibrillation were on average older, more likely to have diabetes mellitus, hypertension, history of stroke/ transient ischaemic attack, congestive heart failure, atrial enlargement, high baseline NIHSS-score and implanted pacemaker. After adjustment by Cox proportional hazard model, sustained atrial fibrillation was not associated with early ischaemic recurrences (adjusted HR 1.23 (95% CI 0.74–2.04)). Conclusions After acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. After adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, thus suggesting that the risk profile associated with atrial fibrillation, rather than its pattern, is determinant for recurrence.

scholarly journals A survey of opinion: When to start oral anticoagulants in patients with acute ischaemic stroke and atrial fibrillation?

2018 ◽  
Vol 3 (4) ◽  
pp. 355-360 ◽  
Author(s):  
David Munn ◽  
Azmil H Abdul-Rahim ◽  
Urs Fischer ◽  
David J Werring ◽  
Thompson G Robinson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trial ◽  
Ischaemic Stroke ◽  
Oral Anticoagulant ◽  
Online Survey ◽  
Oral Anticoagulants ◽  
Optimal Timing ◽  
Stroke Patients ◽  
Oral Anticoagulant Treatment ◽  
Direct Acting

Introduction There is uncertainty regarding the optimal timing for initiation of oral anticoagulant treatment in patients with recent ischaemic stroke and atrial fibrillation. We surveyed the current UK practice and assessed clinician’s opinions of when to use oral anticoagulant in recent stroke patients with atrial fibrillation. Patients and methods An online survey was sent to stroke physicians within the United Kingdom via their national societies. Results One hundred and twenty-one clinicians responded to the survey. Ninety-five percent of responders agreed that there was uncertainty regarding timing of oral anticoagulant initiation after atrial fibrillation-related ischaemic stroke. Thirty-six percent of responders followed the ‘1–3–6–12’ European Society of Cardiology guidelines recommendation. Uncertainty was greater in cases of moderate stroke than in cases of transient ischaemic attack (TIA), mild or severe stroke. Eighty-eight percent of responders would be willing to participate in a clinical trial of early versus later initiation of oral anticoagulant after stroke. Direct-acting oral anticoagulants were the preferred oral anticoagulant of choice. Discussion and Conclusion There is a lack of consensus amongst stroke physicians for when to initiate oral anticoagulant to prevent recurrence in stroke patients with atrial fibrillation. There is little uncertainty regarding TIA. A clinical trial assessing the use of early versus later initiation of direct-acting oral anticoagulant in patients with recent ischaemic stroke and atrial fibrillation would be beneficial.

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