scholarly journals Does prior antithrombotic therapy influence recurrence and bleeding risk in stroke patients with atrial fibrillation or atrial flutter?

2019 ◽  
Vol 27 (7) ◽  
pp. 729-737
Author(s):  
David T Gamble ◽  
Romain Buono ◽  
Mamas A Mamas ◽  
Stephen Leslie ◽  
Joao H Bettencourt-Silva ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Confidence Interval ◽  
Ischaemic Stroke ◽  
Antithrombotic Therapy ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Stroke Patients ◽  
Antithrombotic Treatment ◽  
Long Term Mortality

Background Whilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment. Methods We used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA2DS2-VASc) and bleeding risk score (HEMORR2HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality. Results A total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHA2DS2-VASc (≥2) and high HEMORR2HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48–1.00: p = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71–0.97: p = 0.02)). Conclusions Our study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.

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

Stroke ◽  
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.

Abstract WP379: Sex-specific Effects of Comorbid Diabetes and Depression on Post-stroke Mortality in Individuals With Atrial Fibrillation

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jodi Edwards ◽  
Jessica Colby-Milley ◽  
Jiming Fang ◽  
Limei Zhou ◽  
Baiju R Shah ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Hospital Mortality ◽  
Recurrent Stroke ◽  
Stroke Patients ◽  
Comorbid Depression ◽  
Term Care ◽  
Post Stroke ◽  
Specific Effects ◽  
Long Term Mortality

Background: Comorbid diabetes and depression are highly prevalent in atrial fibrillation (AF) and increase the risk of stroke. Women with AF show higher mortality rates and have worse functional outcomes post-stroke. However, the sex-specific effects of comorbid diabetes and depression on mortality and other adverse outcomes in stroke patients with a history of AF is unclear. Methods: Prospectively collected consecutive patients with ischemic stroke and known AF presenting to designated stroke centres in Ontario (2003-2013). Multinomial regression was used to determine sex-specific associations between diabetes and depression and in-hospital mortality post-stroke in individuals with AF. Cox proportional hazards regression was used to estimate the adjusted hazard of long-term mortality post-stroke and competing risks models to estimate hazards of recurrent stroke/TIA, admission to long-term care, and incident dementia post-discharge. Results: Among 5082 stroke patients with known AF (median age=80, IQR:73-85), female patients were more likely to have comorbid depression than males (63.5% vs. 36.5%) and those with comorbid diabetes and depression were younger (77 yrs) and had more vascular history (HTN, CAD, hyperlipidemia) than those with AF only. For males, comorbid diabetes increased the likelihood of in-hospital mortality post-stroke by 53% (OR=1.53, 95% CI=1.16-2.02), after adjustment for stroke severity, demographic and clinical factors, while comorbid depression did not significantly impact in-hospital mortality and neither diabetes or depression affected in-hospital mortality post-stroke for females. However, diabetes was independently associated with increased hazard of long-term mortality for both female (HR=1.15, 95%CI=1.02-1.29) and male AF stroke patients (HR=1.35, 95%CI=1.19-1.53). No associations with recurrent stroke/TIA, institutionalization or dementia post-stroke were observed for either females or males. Conclusion: In stroke patients with known AF, comorbid diabetes but not depression was independently associated with increased in-hospital mortality for males and increased long-term mortality post-stroke for both females and males.

scholarly journals GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e033283 ◽  
Author(s):  
Frederik Dalgaard ◽  
Karen Pieper ◽  
Freek Verheugt ◽  
A John Camm ◽  
Keith AA Fox ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Major Bleeding ◽  
Risk Model ◽  
Oral Anticoagulants ◽  
External Validation ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Secondary Outcome

ObjectivesTo externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.DesignRetrospective cohort study.SettingDanish nationwide registries.Participants90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.Primary and secondary outcome measuresExternal validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.ResultsOf the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66–83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).ConclusionIn a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

Long-term bleeding risk prediction in ‘real world’ patients with atrial fibrillation: Comparison of the HAS-BLED and ABC-Bleeding risk scores

2017 ◽  
Vol 117 (10) ◽  
pp. 1848-1858 ◽  
Author(s):  
Vanessa Roldán ◽  
Vicente Vicente ◽  
Mariano Valdés ◽  
Gregory Y. H. Lip ◽  
María Asunción Esteve-Pastor ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Real World ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Bleeding Events ◽  
Bleeding Score ◽  
Better Than

SummaryRisk scores in patients with atrial fibrillation (AF) based on clinical factors alone generally have only modest predictive value for predicting high risk patients that sustain events. Biomarkers might be an attractive prognostic tool to improve bleeding risk prediction. The new ABCBleeding score performed better than HAS-BLED score in a clinical trial cohort but has not been externally validated. The aim of this study was to analyze the predictive performance of the ABC-Bleeding score compared to HAS-BLED score in an independent “real-world” anticoagulated AF patients with long-term follow-up. We enrolled 1,120 patients stable on vitamin K antagonist treatment. The HAS-BLED and ABC-Bleeding scores were quantified. Predictive values were compared by c-indexes, IDI, NRI, as well as decision curve analysis (DCA). Median HAS-BLED score was 2 (IQR 2–3) and median ABC-Bleeding was 16.5 (IQR 14.3–18.6). After 6.5 years of follow-up, 207 (2.84%/year) patients had major bleeding events, of which 65 (0.89%/year) had intracranial haemorrhage (ICH) and 85 (1.17%/year) had gastrointestinal bleeding events (GIB). The c-index of HAS-BLED was significantly higher than ABC-Bleeding for major bleeding (0.583 vs 0.518; p=0.025), GIB (0.596 vs 0.519; p=0.017) and for the composite of ICH-GIB (0.593 vs 0.527; p=0.030). NRI showed a significant negative reclassification for major bleeding and for the composite of ICH-GIB with the ABC-Bleeding score compared to HAS-BLED. Using DCAs, the use of HAS-BLED score gave an approximate net benefit of 4% over the ABC-Bleeding score. In conclusion, in the first “real-world” validation of the ABC-Bleeding score, HAS-BLED performed significantly better than the ABC-Bleeding score in predicting major bleeding, GIB and the composite of GIB and ICH.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.

scholarly journals Oral anticoagulant therapy in atrial fibrillation older patients with previous bleeding

2020 ◽  
Vol 90 (1) ◽  
Author(s):  
Mario Bo ◽  
Francesco Giannecchini ◽  
Martina Papurello ◽  
Enrico Brunetti
Keyword(s):  
Atrial Fibrillation ◽  
Anticoagulant Therapy ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulant ◽  
Older Patients ◽  
Oral Anticoagulant Therapy ◽  
Unmet Need ◽  
Bleeding Event ◽  
Bleeding Risk ◽  
Risk Scores

Oral anticoagulant therapy (OAT) with direct oral anticoagulant (DOACs) is the established treatment to reduce thromboembolic risk in patients with atrial fibrillation (AF). Bleeding risk scores are useful to identify and correct factors associated with bleeding risk in AF patients on OAT. However, the clinical scenario is more complex in patients with previous bleeding event, and the decision about whether and when starting or re-starting OAT in these patients remains a contentious issue. Major bleeding is associated with a subsequent increase in both short- and long-term mortality, and even minimal bleeding may have prognostic importance because it frequently leads to disruption of antithrombotic therapy. There is an unmet need for guidance on how to manage antithrombotic therapy after bleeding has occurred. While waiting for observational and randomized data to accrue, this paper offers a perspective on managing antithrombotic therapy after bleeding in older patients with AF.

Abstract 183: Antithrombotic Therapy and Bleeding Risk in a Prospective Cohort Study of Patients with Cerebral Cavernous Malformations (CCM)

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
C Stapf ◽  
D Hervé ◽  
J P Guichard ◽  
D Bresson ◽  
A Soumaré ◽  
...  
Keyword(s):  
Antithrombotic Therapy ◽  
Vascular Malformations ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Antithrombotic Treatment ◽  
Cavernous Malformations ◽  
Retrospective Data Collection ◽  
Risk Of Hemorrhage

BACKGROUND: Cerebral cavernous malformation (CCM) are the most frequently diagnosed vascular malformations in the brain and are often asymptomatic. The potential risk of hemorrhage often precludes antithrombotic treatment in patients with cardiovascular disease, but no systematic study has been undertaken to evaluate the effect of blood-thinning therapy on the risk of CCM hemorrhage. PATIENTS AND METHODS: We prospectively followed consecutive patients with a diagnosis of one or more CCMs in a prospective database since 2008. Retrospective data collection was used for patients with a diagnostic event or imaging studies done prior to first assessment. Symptomatic hemorrhage and other focal neurological events during prospective follow-up were defined according to the current guidelines of the Angioma Alliance Scientific Advisory board RESULTS: A total of 87 patients were prospectively enrolled in our cohort (50 women (57%), mean age 44.8 years (SD +/- 17.6), mean follow up 3.9 years) harboring a total of 738 CCMs. N=55 patients (63%) had a single CCM, and 32 patients (37%) had multiple CCMs. Longitudinal follow-up included 16 (18%) patients receiving long-term antithrombotic therapy by antiplatelet treatment (n=11) or oral anticoagulants (n=5). During 5536 lesion-years of observation, none of the patients under antithrombotic therapy experienced CCM hemorrhage on follow up. CONCLUSION: Our observational data suggest long-term antithrombotic treatment by antiplatelet drugs or warfarin does not increase the frequency of CCM-related hemorrhage. Patients harboring single or multiple CCMs suffering ischemic stroke or heart disease should not be withheld antithrombotic therapy.

Could the PARIS Risk Scores Be Useful for the Choice of Triple vs Dual Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention?

Cardiology ◽  
2022 ◽  
Author(s):  
Leonardo De Luca ◽  
Leonardo Bolognese ◽  
Andrea Rubboli ◽  
Donata Lucci ◽  
Domenico Gabrielli ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Antithrombotic Therapy ◽  
Bleeding Risk ◽  
Daily Practice ◽  
Coronary Intervention ◽  
Risk Scores ◽  
Thrombotic Risk ◽  
Percutaneous Coronary ◽  
Study Results

Introduction. Current guidelines recommend dual antithrombotic therapy (DAT) for the majority of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and suggest a short course of triple antithrombotic therapy (TAT) for those at very high thrombotic risk (TR) but low bleeding risk (BR). Methods. We analyze if the PARIS ischemic-hemorrhagic scale could be useful for the choice of antithrombotic strategy in patients with acute coronary syndromes (ACS) and AF treated with coronary stenting enrolled in the prospective, observational, nationwide MATADOR-PCI study. Results. Among the 588 patients discharged alive, a TAT was prescribed in 381 (64.8%) and DAT in 52 (8.8%) patients. According to the PARIS scoring system, 142 (24.2%) were classified as low, 244 (41.5%) as intermediate and 292 (34.3%) as high TR. In parallel, 87 (14.8%) were categorized in the low, 260 (44.2%) in the intermediate and 241 (41.0%) in the high-risk stratum for major bleedings. Crossing the various strata of the two PARIS risk scores, the largest group of patients consisted of those at high TR and BR (n=130, 22%), followed by those at intermediate risk according to both scores (n=122, 21%). At discharge, TAT was mainly used in patients at intermediate to high BR, while DAT in those at intermediate to high TR but low BR, according to the PARIS score. Conclusion. Our data suggest that some variables associated with increased TR or BR are poorly considered in the daily practice while the use of PARIS scales could help in the implementation of guidelines' recommendations.

scholarly journals Rivaroxaban in patients with atrial fibrillation: from research to real practice (based on REGistry of Long-term AnTithrombotic TherApy-2 (REGATA))

2021 ◽  
pp. 68-88
Author(s):  
E. S. Kropacheva ◽  
E. N. Krivosheeva ◽  
E. P. Panchenko
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Ischemic Stroke ◽  
Antithrombotic Therapy ◽  
Bleeding Risk ◽  
Cardiovascular Death ◽  
Cardiovascular Complications ◽  
Coronary Syndrome

Introduction. Despite the large evidence base for the use of rivaroxaban, cohort studies are interesting because shows the possibility of anticoagulant therapy in patients with high thromboembolic and bleeding risk and a burden of comorbidity in practice.Aim: to evaluate the efficacy and safety of rivaroxaban therapy in patients with atrial fibrillation in prospective REGATTA registry.Materials and methods. This study is a fragment of a single-center prospective REGATA registry (Registry of Long-term Antithrombotic Therapy (NCT043447187), conducted on the basis of the National Research Center of Cardiology of the Ministry of Health of the Russian Federation. 152 patients with high thromboembolic risk (median CHA2DS2-VASc = 4) received rivaroxaban therapy (median follow-up 1.5 years). The efficacy endpoint was the sum of cardiovascular complications (including cardiovascular death, ischemic stroke, and acute coronary syndrome). The safety endpoint bleedinds BARC types 2-5.Results. The frequency of cardiovascular events (combining cardiovascular death, ischemic stroke and acute coronary syndrome) was 5.8/100 patient-years. The use of a “reduced” dose of rivaroxaban was an independent predictor of the development of fatal cardiovascular complications. The rate of major bleeding was 3.7/100 patient-years, and the rate of clinical relevant bleedings was 19.4 /100 patientyears. The predictors of major/ clinical relevant bleedings were chronic kidney disease with a decrease in creatinine clearance of less than 50 ml/min and the anamneses of major/ clinical relevant bleedings.Conclusion. The main requirement for improving the safety of anticoagulants is follow up, focused in all changes in the cardiovascular and somatic status of the patient during treatment.

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