scholarly journals Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study

2021 ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam de Havenon ◽  
Christopher R. Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Binary Logistic Regression ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Cardioembolic Stroke ◽  
Primary Analysis ◽  
Stroke Study ◽  
Increased Risk

Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

scholarly journals Outcome of intravenous thrombolysis for acute ischemic stroke in patients with and without atrial fibrillation

2017 ◽  
Vol 70 (7-8) ◽  
pp. 203-208
Author(s):  
Zeljko Zivanovic ◽  
Dragan Adamovic ◽  
Aleksandra Lucic-Prokin ◽  
Timea Kokai-Zekic ◽  
Jelena Sekaric ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Binary Logistic Regression ◽  
Neurological Status ◽  
Stroke Patients ◽  
Severe Stroke ◽  
Increased Risk ◽  
Favorable Clinical Outcome

Introduction. Atrial fibrillation is associated with an increased risk of ischemic stroke. The benefit of intravenous thrombolysis in patients with acute ischemic stroke and atrial fibrillation is still unclear. The aim of the study was to assess and compare the effects of intravenous thrombolysis in stroke patients with and without atrial fibrillation. Material and Methods. We analyzed stroke patients who were treated with intravenous thrombolysis. Patients were divided into two groups according to the presence of atrial fibrillation. Demographic, clinical and radiological characteristics of patients were compared between the two groups. The treatment efficacy was evaluated in relation to the improvement of neurological status after 24 hours, and functional recovery after three months. Binary logistic regression was used to evaluate predictors of outcome. Results. From a total of 188 patients, 39.4% presented with atrial fibrillation. Patients with atrial fibrillation were older (69.4 vs. 62.6 years; p <0.0001), with female predominance (43.2% vs. 28.9%, p = 0.04) and had clinically more severe stroke (National Institutes of Health Stroke Scale, score on admission 15.4 vs. 12.1; p = 0.0001). Significantly more patients without atrial fibrillation (61.4% vs. 43.2%, p = 0.01) had a favorable clinical outcome at three months after stroke. Nevertheless, atrial fibrillation was not an independent predictor of poor outcome at three months after stroke (p=0.66). Conclusion. Acute ischemic stroke patients, with atrial fibrillation, treated with intravenous thrombolysis, had worse outcomes than patients without atrial fibrillation did. However, it is mainly due to older age and a more severe stroke in patients with atrial fibrillation.

Abstract 3681: Early Anticoagulation Is Not Associated With Hemorrhagic Transformation Of Ischemic Stroke In Patients With Atrial Fibrillation

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
H. B Brouwers ◽  
Svetlana Lorenzano ◽  
Lyndsey H Starks ◽  
David M Greer ◽  
Steven K Feske ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Data ◽  
Infarct Volume ◽  
Hemorrhagic Transformation ◽  
P Value ◽  
Long Term Outcome ◽  
Nihss Score

Purpose: Hemorrhagic transformation (HT) is a common and potentially devastating complication of ischemic stroke, however its prevalence, predictors, and outcome remain unclear. Early anticoagulation is thought to be a risk factor for HT which raises the clinical question when to (re)start anticoagulation in ischemic stroke patients who have a compelling indication, such as atrial fibrillation. We conducted a prospective cohort study to address this question and to identify association of hemorrhagic transformation with outcome measures in patients with atrial fibrillation in the setting of acute ischemic stroke. Materials and Methods: We performed a prospective study which enrolled consecutive patients admitted with acute ischemic stroke presenting to a single center over a three-year period. As part of the observational study, baseline clinical data and stroke characteristics as well as 3 month functional outcome were collected. For this sub-study, we restricted the analysis to subjects diagnosed with atrial fibrillation. CT and MRI scans were reviewed by experienced readers, blinded to clinical data, to assess for hemorrhagic transformation (using ECASS 2 criteria), microbleeds and infarct volumes in both admission and follow-up scans. Clinical and outcome data were analyzed for association with hemorrhagic transformation. Results: Of 94 patients, 63 had a history of atrial fibrillation (67.0%) and 31 had newly discovered atrial fibrillation (33.0%). We identified HT in 3 of 94 baseline scans (3.2%) and 22 of 48 follow-up scans (45.8%) obtained a median of 3 days post-stroke. In-hospital initiation of either anti-platelet (n = 36; OR 0.34 [95% CI 0.10-1.16], p-value = 0.09) or anticoagulation with unfractionated intravenous heparin or low molecular weight heparin (n = 72; OR 0.25 [95% CI 0.06-1.15], p-value = 0.08) was not associated with HT. Initial NIH Stroke Scale (NIHSS) score (median 13.0 [IQR 15.0] vs. 7.0 [IQR 10.0], p-value = 0.029) and baseline infarct volume (median 17 [IQR 42.03] vs. 5 [IQR 10.95], p-value = 0.011) were significantly higher in patients with HT compared to those without. Hemorrhagic transformation was associated with a significantly higher 48-hour median NIHSS score (20 [IQR 3.0] vs. 2 [IQR 3.25], p-value = 0.007) and larger final infarct volume (81.40 [IQR 82.75] vs. 9.95 [IQR 19.73], p-value < 0.001). Finally, we found a trend towards poorer 3-month modified Rankin Scale scores in subjects with HT (OR 11.25 [95% CI 0.97-130.22], p-value = 0.05). Conclusion: In patients with atrial fibrillation, initial NIHSS score and baseline infarct volume are associated with hemorrhagic transformation in acute ischemic stroke. Early initiation of antithrombotic therapy was not associated with hemorrhagic transformation. Patients with hemorrhagic transformation were found to have a poorer short and long term outcome and larger final infarct volumes.

Abstract TP77: Race/Ethnic Disparity Trends in tPA Administration in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle P Lin ◽  
Steven Cen ◽  
Amytis Towfighi ◽  
May Kim-Tenser ◽  
William Mack ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Rate Ratio ◽  
The United States ◽  
Racial Groups ◽  
Primary Analysis ◽  
Targeted Interventions ◽  
Yearly Change ◽  
Administration Rate

Introduction: Prior studies have shown racial disparities in tPA use for acute ischemic stroke. With the implementation of nationwide quality improvement measures, we sought to describe the temporal change in racial disparity in tPA administration. Hypothesis: Disparity in tPA administration improved across all racial groups in the past decade Methods: Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients (N=5,932,175) admitted to hospitals between 2000 and 2010 with a discharge diagnosis of ischemic stroke (ICD9 codes) were included. Primary analysis was the proportion of patients who received tPA administration stratified by race (white, black, Hispanic, Asian) temporally. Survey-weighted Poisson regression was used to estimate the rate ratio and compare the trend for yearly change between race categories. Results: Of the patients with ischemic stroke, 55.4% were white, black 11.89%, Hispanic 5.32%, Asian 1.89%, others 1.77%, missing race 23.31%. tPA administration rate increased from 2000 to 2010 regardless of race. In 2000, tPA administration rate was 0.96%, 0.40%, 0.73%, 0.59% in white, black, Hispanic, Asian, respectively. In 2010, tPA administration rate was 4.0%, 2.14%, 2.09%, 2.13% respectively. The relative change was the greatest in black with rate ratio of 6.7 (5.95-7.54), compared to other racial groups, Asian 5.36 (4.23-6.78), Hispanic 3.93 (3.42-4.51), and white 3.88 (3.74-4.03). Conclusions: Over the last decade, the rate of tPA administration for acute ischemic stroke in the United States have increased for every racial group. There is a lasting but improved disparity in tPA administration in non-white race. Targeted interventions designed to increase treatment and close disparity gap focusing on culturally tailored education and communications to address barriers need to be further explored.

Association Between Mean Platelet Volume and Hemorrhagic Transformation in Acute Ischemic Stroke Patients

2020 ◽  
Vol 17 (1) ◽  
pp. 3-10
Author(s):  
Changyi Wang ◽  
Lu Wang ◽  
Linghui Deng ◽  
Shi Qiu ◽  
Shihong Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mean Platelet Volume ◽  
Generalized Additive Model ◽  
Univariate Analysis ◽  
Additive Model ◽  
Hemorrhagic Transformation ◽  
Dependent Manner ◽  
Platelet Volume ◽  
Increased Risk

Background: Hemorrhagic transformation (HT) is a frequent complication of acute ischemic stroke (AIS). Mean platelet volume (MPV) is a marker of platelet function. The relationship between MPV and HT remains unclear. Methods: From January 1st, 2012 to December 31st 2016, we consecutively enrolled AIS patients admitted to the Department of Neurology of West China Hospital. MPV was measured on admission. HT was diagnosed by brain imaging and classified into hemorrhagic infarct (HI) and parenchymal hematoma (PH). Moreover, subjects were divided into tertiles according to MPV levels. Confounders were identified by univariate analysis and multivariate logistic regression was performed to explore the association between MPV and HT as well as HT subtypes. Also, a generalized additive model was used to investigate whether a non-linear association existed between MPV and HT. Results: A total of 783 AIS patients were included. 63 patients (8.0%) developed HT: 34 (4.3%) HI and 29 (3.7%) PH. It was observed that MPV positively correlated with HT. After adjustment for confounders, patients in the highest MPV tertile had a significantly increased risk of HT compared to patients in the lowest tertile (odds ratio 2.3, 95% confidence interval 1.0-5.4, P=0.04). The risk of HT increased step-wise across MPV tertiles (P for trend=0.04). MPV tertiles significantly correlated with HI rather than PH. The generalized additive model demonstrated a nonlinear association between MPV and HT (P=0.02). Conclusion: The risk of HT increased with increasing MPV level in a dose-dependent manner. Patients with elevated MPV levels were more likely to develop HI rather than PH.

Reduction in the Ratio of Low-density Lipoprotein Cholesterol to Highdensity Lipoprotein Cholesterol is Associated with Increased Risks of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

2019 ◽  
Vol 16 (3) ◽  
pp. 266-272 ◽  
Author(s):  
Yanan Wang ◽  
Chenchen Wei ◽  
Quhong Song ◽  
Junfeng Liu ◽  
Yajun Cheng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Hemorrhagic Transformation ◽  
Lipoprotein Cholesterol ◽  
Low Density ◽  
Low Density Lipoprotein Cholesterol ◽  
Stroke Patients ◽  
Increased Risk

Background and Purpose: Hemorrhagic transformation (HT) is a potentially serious complication in patients with acute ischemic stroke (AIS). Whether the ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol (LDL-C/HDL-C) is associated with HT remains unclear. Methods: Ischemic stroke patients within 7 days of stroke onset from January 2016 to November 2017 were included in this study. Lipid profiles were measured within 24h after admission. HT was determined by a second computed tomography or magnetic resonance imaging within 7 days after admission. Univariate and multivariate logistic regression analysis was used to assess the association between LDL-C/HDL-C and HT. Results: We enrolled 1239 patients with AIS (788 males; mean age, 64 ± 15 years), of whom 129 (10.4%) developed HT. LDL-C/HDL-C was significantly lower on admission in patients with HT than those without HT (2.00 ± 0.89 vs. 2.25 ± 1.02, P=0.009). The unadjusted odds ratio (OR) of low LDL-C/HDL-C for HT was 2.07 (95% confidence interval [CI] 1.42-3.01, P＜0.001). After adjustment for possible confounders, lower LDL-C/HDL-C (≤1.52) was significantly associated with HT (OR 1.53, 95% CI: 1.02-2.31, P=0.046). Similar results were observed between lower LDL-C (≤ 4 mmol/L) and HT (OR 4.17, 95% CI: 1.25-13.90, P=0.02). However, no significant association was found between HT and high HDL-C, low triglycerides or low total cholesterol. Conclusion: Lower LDL-C/HDL-C and LDL-C were significantly associated with increased risk of HT after AIS. Further investigations are warranted to confirm these findings and then optimize lipid management in stroke patients with lower LDL/HDL-C or LDL-C.

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