Ischemic stroke and antithrombotic therapy: key aspects

The paper considers the key areas of antithrombotic therapy for ischemic stroke (IS). Antiplatelet therapy is shown to be a multistage and multidisciplinary strategy of treatment for patients with IS, which begins with the appearance of the first symptoms of the disease and continues throughout life. Each stage, including fibrinolytic therapy, early use of antithrombotic and anticoagulant drugs, and personalized antithrombotic prevention of recurrent cerebral disorders, is important in itself and serves a common goal. As a result, all efforts should be aimed at reducing mortality rates in the acute phase of stroke and the functional dependence of a patient and at preventing venous thromboses, recurrent stroke, and all cardiovascular events to increase life expectancy and to improve quality of life. Fibrinolytic therapy increases the patient’s chances of a full neurologic recovery and improves the quality of later life. Antithrombotic drugs reduce the risk of cardiovascular death, early recurrences of stroke, and recurrent noncardioembolic stroke. Parenteral anticoagulants in acute stroke decrease the risk of venous thrombosis/thromboembolism, oral anticoagulants reduce that of recurrent cardioembolic stroke.

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Abstract P252: Discharge Antithrombotic Therapy for Ischemic Stroke Patients With Prior Aspirin Failure

Stroke ◽

10.1161/str.52.suppl_1.p252 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Deepak L Bhatt ◽

Gregg C Fonarow ◽

Eric E Smith ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Prevention ◽

Antithrombotic Therapy ◽

Recurrent Stroke ◽

Oral Anticoagulants ◽

The United States ◽

Future Research ◽

Large Artery ◽

Secondary Stroke Prevention ◽

Stroke Registry

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients. Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017. Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge. Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

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Recurrent ischemic stroke in patients with atrial fibrillation: frequency, heterogeneity, prevention

Atherothrombosis Journal ◽

10.21518/2307-1109-2020-2-7-16 ◽

2020 ◽

pp. 7-16

Author(s):

L. A. Geraskina ◽

M. M. Alieva ◽

A. V. Fonyakin ◽

M. Yu. Maximova ◽

N. I. Garabova ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Recurrent Stroke ◽

Dynamic Assessment ◽

Oral Anticoagulants ◽

Antiplatelet Agents ◽

Antithrombotic Agent ◽

Retrospective Assessment ◽

Prevention Therapy

Introduction. For the prevention of recurrent ischemic stroke (IS) in patients with atrial fibrillation (AF), oral anticoagulants (OAC) are considered a priority. The comorbidity of AF patients raises a discussion about the non-alternative feasibility and exceptional clinical efficacy of OAC. The validity of the choice of a specific antithrombotic agent can be assessed using a dynamic assessment of the causes of the first and recurrent stroke in patients with AF.Aim. To assess the frequency recurrent IS and quality of medicament prevention therapy in patients with AF depend on heterogeneity of stroke leading pathogenetic mechanism.Materials and methods. The data from the register of 200 patients with IS and AF were analyzed. 55 (27.5%) patients suffered recurrent IS (24 (43,6%) men, 31 (56,4%) women, mean age 72,3 ± 10,2 years). The pathogenetic subtype of recurrent IS was determined, including a retrospective assessment of the pathogenetic subtype of a previous IS. We studied the presence and nature of antithrombotic therapy (ATT) preceding a second stroke.Results. The first IS was due to cardiogenic embolism in 36.4% of patients, the atherothrombotic subtype occurred in 18.2%, and the lacunar subtype in 34.5% of patients. Embolic stroke from an undetermined source (ESUS) - in 10.9% of patients. OACs were prescribed only to 31.7% of patients, antiplatelet agents - to 14.6% of patients, 53.7% of patients did not receive ATT. The leading pathogenetic subtype of recurrent stroke was cardiogenic embolism (70.7%), the frequency of lacunar stroke decreased (4.9%), and the frequency of atherothrombotic stroke remained unchanged. In 14 patients with recurrent stroke, AF was first detected, including all patients with ESUS.Conclusion. The proportion of recurrent stroke in patients with AF is 27.5%. Compared with the first stroke, recurrent stroke in patients with AF is characterized by an increase in the proportion of cardiogenic embolism up to 70.7%, which is due to the insufficient prescription of OAC, which must be recommended, including for patients with non-cardioembolic subtypes of stroke.

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Changes in Antithrombotic Therapy of Atrial Fibrillation in the Hospital in 2011-2012 and 2016-2017 (Pharmacoepidemiological Analysis)

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2020-10-10 ◽

2020 ◽

Vol 16 (5) ◽

pp. 686-692

Author(s):

O. V. Reshetko ◽

A. V. Sokolov ◽

N. V. Furman ◽

V. V. Agapov

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

High Risk ◽

Antithrombotic Therapy ◽

Heart Defects ◽

Oral Anticoagulants ◽

Prosthetic Heart Valve ◽

Saratov Region ◽

Coronary Syndrome ◽

Risk Of Bleeding

Aim. To study the changes that have occurred in the pharmacotherapy of atrial fibrillation (AF) in the Saratov Region for 5 years by analyzing the antithrombotic therapy of patients who were admitted in a specialized department of the multidisciplinary hospital in Saratov in 2011-2012 and in 2016-2017.Material and methods. A pharmacoepidemiological retrospective study was conducted. The object of the study was the medical records of inpatients (Form 003/y) with the diagnosis “Atrial fibrillation” (ICD-X code I48), that consecutively admitted to the cardiology department of the multidisciplinary hospital in Saratov from January 1, 2011 to December, 31, 2012 (n=211) and from January 1, 2016 to December, 31, 2017 (n=227). Criteria for inclusion in the study: patients over 18 years of age, established diagnosis of non-valvular AF of ischemic genesis. Exclusion criteria from the study: non-ischemic cardiomyopathy, thyrotoxicosis, congenital heart defects, rheumatic heart damage, acute coronary syndrome, endocarditis, myocarditis, pericarditis, pulmonary thromboembolism, the presence of prosthetic heart valve. Pharmacoepidemiological analysis was carried out for the drugs prescribed during hospitalization and given by doctors at discharge of patients from the hospital. The risk of ischemic stroke was assessed using the CHA2DS2-VASc score, and the risk of bleeding – according to the HAS-BLED score.Results. When analyzing the risk of ischemic stroke, it was found that 100% of patients in 2011-2012 years and 98.2% in 2016-2017 years had indications for the prescription of oral anticoagulants (OAСs). In 2011-2012 there were no patients with a low risk of stroke (CHA2DS2-VASc=0). High risk of bleeding (HAS-BLED≥3) occurred in 4.7% of patients in 2011-2012 and in 10.6% in 2016-2017, however, due to the high risk of stroke, the refusal to prescribe OAC in these patients was inappropriate in accordance with the recommendations for the treatment of AF. In the group of patients with CHA2DS2-VASc=0 in 2016-2017 antiplatelet therapy was prescribed in 100% at the hospital stage and at discharge, which contradicts the guidelines, according to which antithrombotic therapy is not recommended to patients with CHA2DS2-VASc=0. In patients with CHA2DS2-VASc=1, a low percentage of anticoagulants prescription was noted. In 2016-2017 OACs were prescribed only in 12.5% of patients at all stages of observation. In 2011-2012 OAC alone was prescribed only to 1 person (20%) at the hospital stage, which does not comply with modern guidelines for the treatment of patients with AF, according to which patients with a risk score CHA2DS2-VASc=1 are recommended to receive OACs in the absence of contraindications. OACs prescription in group CHA2DS2-VASc≥2 occurred only in 15% of patients in 2011-2012 and in a third of patients in 2016-2017 (p<0.05). The frequency of isolated use of OACs significantly increased in 2016-2017 compared to 2011-2012 mainly due to the increase in the spectrum of direct OACs (DOACs) (p<0.05).Conclusion. For 5 years there have been significant changes in the antithrombotic therapy of AF in the Saratov Region. The frequency of prescribing OACs according to indications has increased mainly due to the introduction of the DOACs into clinical practice. However, prevention of stroke remains insufficient.

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Prognostic factors of cardiovascular death in patients with ischemic stroke in the long-term follow up

Cardiosomatics ◽

10.26442/cs45258 ◽

2016 ◽

Vol 7 (3-4) ◽

pp. 97-103

Author(s):

A. V Fonyakin ◽

L. A Geraskina ◽

V. A Shandalin

Keyword(s):

Ischemic Stroke ◽

Sinus Rhythm ◽

Recurrent Stroke ◽

Low Frequency ◽

Holter Monitoring ◽

Multivariate Regression Analysis ◽

Cardiovascular Death ◽

Increased Risk ◽

Two Parameters

In a prospective observational non-interventional study included 148 patients with ischemic stroke at the age of 60 (52; 68) years, with sinus rhythm. At the end of the acute stroke period (21-22 days) was performed Holter monitoring with the assessment of arrhythmias and heart rate variability (HRV). Duration of prospective follow-up was 35 (28; 40) months. We register all cases of cardiovascular death (CD), including death due to recurrent stroke, myocardial infarction (MI), sudden CD (SCD), acute heart failure (AHF), pulmonary embolism. During follow up CD was registered in 15 (10%) patients: in 7 patients - due to recurrent stroke, 2 patients - due to acute MI, in 3 - due to AHF, 3 patients - due to SCD. On multivariate regression analysis in sinus rhythm revealed significant association with the development of CD following factors: age over 67 years, male gender, involvement insula in the area of ischemic damage, supraventricular extrasystoles (more than 54 extrasystoles per day), ventricular arrhythmias, bradyarrhythmias, reduced power range of high-frequency (HF) less than 39 ms2 and low frequency less than 180 ms2 HRV. Separately from the number of these factors with increased risk of fatal complications was significantly associated only two parameters: the involvement insula in the cerebral infarct area (p

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Abstract 63: Three-month Outcomes in Japanese Stroke /TIA Patients With Non-valvular Atrial Fibrillation After Initiating Oral Anticoagulants: The SAMURAI-NVAF Study

Stroke ◽

10.1161/str.46.suppl_1.63 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Shoji Arihiro ◽

Kenichi Todo ◽

Masatoshi Koga ◽

Hiroshi Yamagami ◽

Tadashi Terasaki ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Recurrent Stroke ◽

Oral Anticoagulants ◽

Bleeding Events ◽

Nonvalvular Atrial Fibrillation ◽

Fatal Bleeding ◽

Index Stroke ◽

Ischemic Events

Backgound and Purpose: Recently, three non-vitamin K antagonist oral anticoagulants (NOACs) became available for patients with nonvalvular atrial fibrillation (NVAF) in Japan. We aimed to determine 3-month outcomes in ischemic stroke/TIA patients receiving NOACs or warfarin from a multicenter prospective registry (SAMURAI-NVAF registry, NCT01581502). Methods: Among 1,191 acute ischemic stroke /TIA patients enrolled between September 2011 and March 2014, we studied 916 patients (389 women, 77±10 y) who took oral anticoagulants (OACs) after index stroke and completed 3-month follow-up survey. Primary outcome measures were ischemic events, including recurrent stroke/TIA and thromboembolism, and major bleedings events, such as fatal bleeding and/or symptomatic bleeding in a critical area or organ according to the International Society on Thrombosis and Haemostasis statement. We assessed the incidence and clinical factors associated with primary outcomes within 90 days after initiating OACs. Results: NOACs were given for 370 patients (126 women, 74±9 y; dabigatran 168, rivaroxaban 183 and apixaban 19) and warfarin for 546 (263 women, 79±10 y). NOAC users had lower scores of CHADS2 (median 3 in NOAC, 4 in warfarin, p<0.001) and HAS-BLED (3, 3, p<0.001) than warfarin users. Ischemic events occurred in 14 NOAC users (3.8%; 2 women, 76±6 y, including 8 lower dose users between two approved dose for each NOAC) and 25 warfarin users (4.6%; 13 women, 81±9 y). Of these, 13 NOAC users (3.5%) and 16 warfarin users (2.9%) developed ischemic stroke/TIA. Among NOAC users, patients with ischemic events had lower body weights (53±11 vs 60±11kg, p= 0.017), more frequently had congestive heart failure (36 vs 10%, p = 0.003) and intracardiac thrombus (27 vs 4%, p < 0.001) than those without. Major bleeding events occurred in 5 NOAC users (1.4%, all using lower dose), and 14 warfarin users (2.6%). Of these, one NOAC user (0.3%) and 4 warfarin users (0.7%) developed intracranial hemorrhage. Conclusion: The 3-month incidence of ischemic events in stroke/TIA patients with NVAF was approximately 4% in both NOAC and warfarin users. Intracranial hemorrhage was relatively infrequent in NOAC users.

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The Efficacy, Safety and Adherence to Treatment when New Anticoagulants Taking in Over 75 Years Old Patients with Atrial Fibrillation

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2020-20-07 ◽

2020 ◽

Vol 16 (1) ◽

pp. 10-18

Author(s):

A. N. Turov ◽

S. V. Panfilov ◽

О. V. Tschiglinzeva

Keyword(s):

Myocardial Infarction ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Oral Anticoagulants ◽

Daily Intake ◽

Cardiovascular Death ◽

New Oral Anticoagulants ◽

Minor Bleeding ◽

Observation Study ◽

Old Patients

Aim. To study the efficacy, safety, and adherence to therapy with new oral anticoagulants in patients older than 75 years with atrial fibrillation.Material and methods. Patients (n=431) over 75 years old (82.7±3.4 years) with various types of atrial fibrillation/flutter (AF) were included in a nonrandomized observational study of new oral anticoagulants (NOAC) in real clinical practice. A history of cardiac surgery was in 27.6% of patients. All patients had >3 risk factors for ischemic stroke (CHA2DS2-VASс 4.81±0.4 points) and >1 risk factor for bleeding (HAS-BLED 3.01±0.2 points). The duration of the observation study was from 12 to 42 (26.9±4.9) months. Dabigatran was taken in 38.5% (n=166) of patients, rivaroxaban – in 41.3% (n=178), apixaban – in 20.2% (n=87) of patients.Results. The incidence of new cases of myocardial infarction was 0.8% per year, surgical revascularization – 0.9% per year, cardiovascular death – 0.8% per year. The frequency of ischemic stroke was 1.1% per year, transient ischemic attacks – 0.4% per year, all thromboembolic episodes – 1.77% per year. The incidence of intracranial hemorrhage was 0.2% per year, of minor bleeding – 4.4% per year, of the combined cardiac point (the total frequency of all strokes, major bleeding, myocardial infarction, mortality from cardiovascular causes, revascularization procedures) – 4.2% per year. Significant differences in the frequency of endpoints depending on the drug of NOAC taken by patients were not found. Violations of the regimen and doses were more often observed with twice daily intake (63.9% for dabigatran and 59.8% for apixaban) than with a single dosage regimen per day (45.5% for rivaroxaban). The leading causes of non-adherence to NOAC therapy in patients over 75 years of age included skipping the next scheduled dose (43.6%) and changing the frequency of the drug taking (16.9%). For NOAC with a double dose per day, dabigatran and apixaban, the frequency of administration was violated in 27.7% and 28.7%, respectively, and with a single dose per day, rivaroxaban – in 1.1%.Conclusion. Therapy with NOAC in patients older than 75 years with AF is effective and safe. There were no statistically significant differences in the incidence of thromboembolic or hemorrhagic events during three NOACs treatment in patients with AF older than 75 years. The incidence of non-adherence was less

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CHA2DS2-VASc score in acute ischemic stroke with atrial fibrillation: results from the Clinical Research Collaboration for Stroke in Korea

Scientific Reports ◽

10.1038/s41598-020-80874-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Hak-Loh Lee ◽

Joon-Tae Kim ◽

Ji Sung Lee ◽

Beom Joon Kim ◽

Jong-Moo Park ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Primary Outcome ◽

Research Collaboration ◽

Recurrent Stroke ◽

Oral Anticoagulants ◽

Vascular Events ◽

Stroke Registry ◽

One Year

AbstractWe investigated a multicenter registry to identify estimated event rates according to CHA2DS2-VASc scores in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). The additional effectiveness of antiplatelets (APs) plus oral anticoagulants (OACs) compared with OACs alone considering the CHA2DS2-VASc scores was also explored. This study retrospectively analyzed a multicenter stroke registry between Jan 2011 and Nov 2017, identifying patients with acute ischemic stroke with AF. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 1 year. A total of 7395 patients (age, 73 ± 10 years; men, 54.2%) were analyzed. The primary outcome events at one year ranged from 5.99% (95% CI 3.21–8.77) for a CHA2DS2-VASc score of 0 points to 30.45% (95% CI 24.93–35.97) for 7 or more points. After adjustments for covariates, 1-point increases in the CHA2DS2-VASc score consistently increased the risk of primary outcome events (aHR 1.10 [1.06–1.15]) at 1-year. Among OAC-treated patients at discharge (n = 5500), those treated with OAC + AP (vs. OAC alone) were more likely to experience vascular events, though among patients with a CHA2DS2-VASc score of 5 or higher, the risk of primary outcome in the OAC + AP group was comparable to that in the OAC alone group (Pint = 0.01). Our study found that there were significant associations of increasing CHA2DS2-VASc scores with the increasing risk of vascular events at 1-year in AIS with AF. Further study would be warranted.

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Direct-acting Anticoagulants in Chronic Coronary Syndromes

European Cardiology Review ◽

10.15420/ecr.2018.24.2 ◽

2020 ◽

Vol 15 ◽

Author(s):

Emmanuel Sorbets ◽

Philippe Gabriel Steg

Keyword(s):

Major Bleeding ◽

Antithrombotic Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Cardiovascular Death ◽

Once Daily ◽

P2y12 Inhibitor ◽

Coronary Syndromes ◽

Direct Acting

Direct-acting oral anticoagulants (DOACs) are easier to use, safer than and as effective as vitamin K antagonists (VKA) in the treatment of non-valvular AF (NVAF). Because of their favourable safety profile and easier use than VKAs, DOACs as anti-thrombotic therapy may have a role in the management of chronic coronary syndromes (CCS). To date, few studies have evaluated DOACs in this setting. Initial studies have focused on patients receiving DOACs for NVAF undergoing acute or elective percutaneous coronary intervention who additionally require dual antiplatelet therapy (DAPT). Rivaroxaban 15 mg once daily plus a P2Y12 inhibitor compared with a VKA regimen was associated with a reduction of bleedings (HR 0.59; 95% CI [0.47–0.76]; p<0.001). Rivaroxaban 2.5 mg twice daily plus DAPT up to 12 months followed by rivaroxaban 15 mg once daily plus P2Y12 inhibitor showed similar results. Dabigatran 110 mg twice daily plus a P2Y12 inhibitor versus a VKA regimen was associated with a reduction of bleedings (HR 0.52; 95% CI [0.42–0.63]; p<0.001), after a mean follow-up of 14 months. A dabigatran 150 mg regimen showed similar results. Apixaban 5 mg twice daily plus a P2Y12 inhibitor versus a VKA regimen confirmed at 6 months the safety of DOACs with a reduction of bleedings (HR 0.69; 95% CI [0.58–0.81]; p<0.001 for non-inferiority and superiority). Edoxaban 60 mg once daily plus a P2Y12 inhibitor was non-inferior to a VKA regimen on bleeding outcomes (major bleeding or non-major clinically relevant non-major bleeding) after a 12-month follow-up (HR 0.83; 95% CI [0.65–1.05]; p=0.001 for non-inferiority; p=0.1154 for superiority). Meta-analysis of these four trials confirmed the safety of DOACs regarding bleeding outcomes, but showed a trend toward stent thrombosis for dual antithrombotic therapy using DOACs versus triple antithrombotic therapy using VKAs. DOACs may show promise in the management of high-risk patients with chronic coronary syndromes. In these patients, rivaroxaban 2.5 mg twice daily in addition to aspirin was shown to reduce the composite outcome of cardiovascular death, stroke or MI compared to aspirin alone (HR 0.76; 95% CI [0.66–0.86]; p<0.001). All-cause death, cardiovascular death and stroke were also significantly lower. This benefit was at the cost of an increase in non-fatal bleeding.

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Efficacy and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients as part of multicomponent antithrombotic therapy

Kardiologicheskii vestnik ◽

10.36396/ms.2020.81.60.007 ◽

2020 ◽

pp. 46-56

Author(s):

Е.Н. Кривошеева ◽

Е.С. Кропачева ◽

Е.П. Панченко ◽

О.А. Землянская ◽

А.Н. Самко

Keyword(s):

Antithrombotic Therapy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cardiovascular Death ◽

Efficacy And Safety ◽

Coronary Syndrome ◽

Venous Thromboembolic Events ◽

Safety Endpoint ◽

Venous Thromboembolic ◽

Clinically Significant

Цель исследования. Сравнение эффективности и безопасности ПОАК и варфарина в составе многокомпонентной антитромботической терапии у больных ФП в условиях реальной клинической практики. Материалы и методы. Исследование представляет собой анализ пар больных, сопоставимых по риску инсульта, кровотечения и наличию сопутствующих заболеваний, получавших ПОАК или варфарин в составе МАТ и наблюдающихся в отделе клинических проблем атеротромбоза НМИЦ кардиологии в рамках регистра РЕГАТА 2. Влияние приема ПОАК и варфарина в составе МАТ на частоту комбинированной конечной точки эффективности (острый коронарный синдром, ишемический инсульт, венозные тромбоэмболические осложнения и сердечно-сосудистая смерть), а также конечной точки безопасности (геморрагические осложнения BARC 2–5) оценивали с помощью критерия Log-Rank. Отдельно проанализированы подгруппы больных в зависимости от уровня создаваемой антикоагуляции (принимавшие уменьшенную и полную дозы ПОАК и варфарин с уровнем TTR ≥ 65% и < 65%). Результаты. Всего в исследование включена 81 пара пациентов (77,8% мужчины, средний возраст 67,2±7,6 лет). Медиана суммы баллов по шкале CHA2DS2-VASc составила 4, по шкале HAS-BLED – 3, медиана индекса Charlson – 6. В группе варфарина медиана TTR составила 67,0 %. Уменьшенную дозу ПОАК лечащие врачи назначили половине (50,6%) пациентов. Медиана длительности наблюдения составила 12 мес. ПОАК в полной дозе и варфарин с уровнем TTR ≥ 65 % в составе МАТ одинаково эффективны в отношении риска тромботических событий [OP 1.12, ДИ 0.34–3.71]. Назначение ПОАК в уменьшенной дозе ассоциируется с достоверным увеличением частоты всех тромботических событий по сравнению с пациентами, получавшими полную дозу ПОАК или варфарин с уровнем TTR≥65% (Log-Rank p=0,0378). В условиях ежемесячного контроля уровня антикоагуляции частота больших и клинически значимых кровотечений одинакова на фоне приема ПОАК и варфарина в составе МАТ (Log-Rank p=0,7286). Медиана длительности приема МАТ до первого большого или клинически значимого кровотечения составила 41 день. Заключение. Мерами, направленными на повышение безопасности и эффективности МАТ, является ограничение сроков комбинированного антитромботического лечения с назначением полной дозы ПОАК или варфарина с уровнем TTR≥65%. Aim of the study. To compare efficacy and safety of DOACs and warfarin as part of multicomponent antithrombotic therapy in AF patients in real clinical practice. Materials and methods. The study is an analysis of 81 pairs of patients comparable for CHA2DS2-VASc, HAS-BLED scores, and Charlson comorbidity index, of patients receiving DOACs or warfarin as part of multicomponent antithrombotic therapy who observed in the department of clinical problems of atherothrombosis of the NMIC cardiology under the REGATA Register 2. Influence of DOACs and warfarin as a part of MAT on the frequency of the composite efficacy endpoint (acute coronary syndrome, ischemic stroke, venous thromboembolic events and cardiovascular death) and safety endpoint (hemorrhagic complications BARC types 2–5) were assessed using the Log-Rank criterion. Also were analyzed subgroups of patients depending on anticoagulation level (patients received reduced and full doses of DOACs and warfarin with a TTR level of ≥ 65% and <65%). Results. The study included 81 pairs of patients (77,8% men, mean aged 69 ± 8,2 years). The median total score CHA2DS2-VASc was 4, HAS-BLED score – 3, the median of the Charlson index composed – 6. In the warfarin group, the median TTR was 67%. Half (52%) of AF patients received reduced DOACs doses. Median follow up period was 12 month. Frequency of all thrombotic events for full DOACs doses and warfarin with a TTR level of ≥ 65 was similar [HR 1.12, CI 0.34–3.71] in AF patients requiring multicomponent antithrombotic therapy. Reduced DOACs doses are associated with significant increase in the frequency of all thrombotic events compared to patients who received full DOACs doses or warfarin with TTR level of ≥ 65 (Log-Rank p = 0.0378). In case of monthly monitoring of INR level frequency of major and clinically significant bleeding was similar for warfarin with regular monitoring of INR level and DOACs (Log-Rank p = 0.7286). Median duration of MAT before first BARC 2-3 type bleeding was 41 days. Сonclusions. The best option to improve the safety and efficacy of MAT is limiting the duration of combined antithrombotic treatment and prescribing a full dose of DOACs or warfarin with a TTR ≥ 65% level.

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