Management of patients after ischemic stroke

2020 ◽  
Vol 25 (5) ◽  
pp. 51-57
Author(s):  
V. A. Parfenov
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Antihypertensive Drugs ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
International Normalized Ratio ◽  
Excess Body Weight ◽  
Nonvalvular Atrial Fibrillation ◽  
Regular Intake

Rehabilitation and secondary prevention of ischemic stroke (IS) is the basis for the management of patients with ischemic stroke. The important role of non-drug methods of secondary prevention of IS should be noted: cessation of smoking and alcohol abuse, regular physical activity, proper nutrition, reduction of excess body weight. The normalization of blood pressure is one of the most effective areas of IS prevention. It is based on the regular intake of antihypertensive drugs in most cases. After noncardioembolic IS, antiplatelet agents are required: acetylsalicylic acid (ASA), clopidogrel, or a combination of dipyridamole and ASA. The possibility of taking a combination of clopidogrel and ASA for 21 days after IS with a subsequent switch to monotherapy with ASA or clopidogrel is discussed in patients with non-disabling IS. After cardiomoembolic IS, warfarin is required under the control of an international normalized ratio or with nonvalvular atrial fibrillation of new oral anticoagulants: apixaban, dabigatran or rivaroxaban. Most patients after IS require statins, and the doses are selected individually. Carotid endarterectomy is most effective in severe stenosis (narrowing of 70–99% of the diameter) of the internal carotid artery on the side of the involved hemisphere during the first 3–7 days after non-disabling IS. The data of multicenter placebo-controlled and open observational studies on the use of the metabolic drug Cytoflavin, which is widely used in our country in the rehabilitation of patients with IS, are presented.

scholarly journals Optimal international normalized ratio (INR) in secondary prevention of stroke in non-valvular atrial fibrillation.

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 378-378
Author(s):  
Masahiro Yasaka MD ◽  
Kazuo Minematsu MD ◽  
Takenori Yamaguchi MD
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Secondary Prevention ◽  
The Elderly ◽  
International Normalized Ratio ◽  
Elderly Group ◽  
Occurrence Rate ◽  
Nonvalvular Atrial Fibrillation ◽  
Hemorrhagic Complications ◽  
Major Stroke

P213 [Purpose] In order to elucidate optimal international normalized ratio (INR) for secondary prevention of stroke in nonvalvular atrial fibrillation (NVAF), we evaluated risk of severe recurrent ischemic stroke and major hemorrhagic complications according to patients’ age and INR. [Methods] We analyzed data of two prospective studies, Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study (Stroke 2000; 31: 817) and NCVC NVAF Secondary Prevention Study to elucidate relationships of major ischemic stroke and hemorrhage with INR. In both studies, all patients with cardioembolic stroke were given warfarin, monitored with INR every month, and followed up for primary endpoints of ischemic stroke and embolism to other part of the body, and for secondary endpoints of major hemorrhagic complications. There were 206 patients enrolled in total (154 men and 52 women). We divided them into two groups, elderly group aged 70 years or more (n=109, median INR 1.6–1.8) and non-elderly group aged less than 70 years (n=97, median INR 1.8–2.0). We calculated annual occurrence rate of major stroke (NIH stroke scale score >= 10) and severe hemorrhagic complications in the two groups. [Results] During the mean follow-up period of 548 days, major stroke was seen in 4 patients with INR<1.6 only in the elderly group (INR=0.95, 1.28, 1.54, 1.57; 13.3%/y in INR<1.6), but in none in the non-elderly group (p=0.0475, Fisher’s exact test between the two groups). In the elderly group, severe hemorrhagic complications occurred in none with INR<2.2 (0%/y), in 5 patients with INR between 2.2 and 3.0 (INR=2.25, 2.59, 2.66, 2.80, 2.98, 17.3%/y), and 2 with INR>=3.0 (INR=3.05, 3.13; 38.4%/y). They occurred in none with INR<3.0 (0%/y) and in 1 with INR>3.0 (INR=3.55, 16.4%/y) in the non-elderly group (p=0.0275 v.s. the elderly group). [Conclusions] Both major ischemic stroke and hemorrhage occur more frequently in the elderly than in the non-elderly. In the elderly group, INR between 1.6 and 2.2 seems optimal to prevent both major stroke and hemorrhage, while INR below 3.0 is desired in the non-elderly group to avoid hemorrhagic complications.

scholarly journals Multifactorial Background for a Low Biological Response to Antiplatelet Agents Used in Stroke Prevention

Medicina ◽  
2021 ◽  
Vol 57 (1) ◽  
pp. 59
Author(s):  
Adam Wiśniewski
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Antiplatelet Therapy ◽  
Negative Impact ◽  
Platelet Reactivity ◽  
Antiplatelet Agent ◽  
Biological Response ◽  
Antiplatelet Agents ◽  
Platelet Inhibition ◽  
High Risk Group

Effective platelet inhibition is the main goal of the antiplatelet therapy recommended as a standard treatment in the secondary prevention of non-embolic ischemic stroke. Acetylsalicylic acid (aspirin) and clopidogrel are commonly used for this purpose worldwide. A low biological response to antiplatelet agents is a phenomenon that significantly reduces the therapeutic and protective properties of the therapy. The mechanisms leading to high on-treatment platelet reactivity are still unclear and remain multifactorial. The aim of the current review is to establish the background of resistance to antiplatelet agents commonly used in the secondary prevention of ischemic stroke and to explain the possible mechanisms. The most important factors influencing the incidence of a low biological response were demonstrated. The similarities and the differences in resistance to both drugs are emphasized, which may facilitate the selection of the appropriate antiplatelet agent in relation to specific clinical conditions and comorbidities. Despite the lack of indications for the routine assessment of platelet reactivity in stroke subjects, this should be performed in selected patients from the high-risk group. Increasing the detectability of low antiaggregant responders, in light of its negative impact on the prognosis and clinical outcomes, can contribute to a more individualized approach and modification of the antiplatelet therapy to maximize the therapeutic effect in the secondary prevention of stroke.

Hematologic Abnormalities in Chronic Kidney Disease

2018 ◽  
Author(s):  
Michael Auerbach ◽  
John Anderson ◽  
Khalid Al Talib
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Oral Anticoagulants ◽  
Infusion Reaction ◽  
Nonvalvular Atrial Fibrillation ◽  
Novel Oral Anticoagulant ◽  
Before And After ◽  
Iv Iron ◽  
A Minor

The focus of this review is on information practical to the practicing nephrologist and internists managing patients with chronic kidney disease (CKD), with an emphasis on the quantitative aspects of risk, diagnosis, treatment, and prognosis. Consequently, anemia associated with non–dialysis-associated CKD is emphasized, with special attention to the role of erythropoiesis-stimulating agents and intravenous (IV) iron in treating the anemia of CKD, as well as sections on uremic bleeding and anticoagulation in CKD patients. Figures show a patient before and after a minor infusion reaction, an algorithm outlining grading and management of acute hypersensitivity reactions to IV iron infusions, and an algorithm for the management of uremic platelet dysfunction. Tables list Food and Drug Administration-recommended dose adjustments for novel oral anticoagulant (NOACs) in CKD patients, evidence for preprocedural withholding of NOACs, and management guidelines for anticoagulation in nonvalvular atrial fibrillation and venous thromboembolism. This review contains 2 highly rendered figures, 3 tables, and 101 references. Key words: Chronic kidney disease; CKD; Anemia of chronic kidney disease; Anemia of CKD; Uremic bleeding; Anticoagulation in CKD; Novel oral anticoagulants in CKD; NOAC CKD

scholarly journals Problems of Cardioembolic Stroke Primary and Secondary Prevention in the Latvian Population / Kardioemboliska Cerebrāla Infarkta Primārās un Sekundārās Profilakses Problēmas Latvijā

2015 ◽  
Vol 69 (5) ◽  
pp. 199-204
Author(s):  
Kristaps Jurjāns ◽  
Santa Sabeļnikova ◽  
Evija Miglāne ◽  
Baiba Luriņa ◽  
Oskars Kalējs ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Secondary Prevention ◽  
Patient Group ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Cardioembolic Stroke ◽  
University Hospital ◽  
Primary And Secondary Prevention ◽  
Stroke Patients ◽  
Very High

Abstract Atrial fibrillation is one of major risk factors of cerebral infarction. The use of oral anticoagulants is the only evidence-based method of reducing the risk of cardioembolic accidents. The guidelines of oral anticoagulant admission and usage have been available since 2012. The results of this study show that of 550 stroke patients that were admitted to Pauls Stradiņš Clinical University Hospital, Rīga, Latvia, from 1 January 2014 until 1 July 2014, atrial fibrillation was diagnosed in 247 (45%) cases, and of these patients, only 8.5% used oral anticoagulants before the onset of stroke. Six months after discharge of 111 (44.9%) stroke survivors, five (4.5%) used no secondary prevention medication, 27 (24.3%) used antiplatelet agents, 54 (48.6%) warfarin, and 25 (22.5%) used target specific oral anticoagulants (TSOACs). The mortality rate was significantly higher in the patient group that used no secondary prevention medication or antiplatelet agents compared to the patient group that used oral anticoagulants. The use of oral anticoagulants for primary stroke prevention in Latvia is insufficient. The mortality of cardioembolic stroke in 180 days is very high - 40.4%. Secondary prevention is essential to prevent recurrent cardioembolic accidents.

scholarly journals Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation

2020 ◽  
Vol 10 (2) ◽  
pp. 44-49
Author(s):  
Michela  Giustozzi ◽  
Giancarlo Agnelli ◽  
Silvia Quattrocchi ◽  
Monica Acciarresi ◽  
Andrea Alberti ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Medical Information ◽  
Treatment Guidelines ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Anticoagulant Treatment ◽  
Anticoagulation Treatment

Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value <2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.

scholarly journals Role of Biological Markers for Cerebral Bleeding Risk STRATification in Patients with Atrial Fibrillation on Oral Anticoagulants for Primary or Secondary Prevention of Ischemic Stroke (Strat-AF Study): Study Design and Methodology

Medicina ◽  
2019 ◽  
Vol 55 (10) ◽  
pp. 626 ◽  
Author(s):  
Anna Poggesi ◽  
Carmen Barbato ◽  
Francesco Galmozzi ◽  
Eleonora Camilleri ◽  
Francesca Cesari ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Biological Markers ◽  
Oral Anticoagulant ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Circulating Biomarkers ◽  
Cerebral Mri

Background and Objectives: In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. Cerebral small vessel disease (SVD) represents the pathologic substrate for primary intracerebral hemorrhage and ischemic stroke. We hypothesize that biological markers—both circulating and imaging-based—and their possible interaction, might improve the prediction of bleeding risk in AF patients under treatment with any type of oral anticoagulant. Materials and Methods: The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with AF, aged 65 years or older, and with no contraindications to magnetic resonance imaging (MRI), referring to Center of Thrombosis outpatient clinic of our University Hospital for the management of oral anticoagulation therapy. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral MRI, and circulating biomarkers assessment at baseline and after 18 months. The main outcome is SVD progression—particularly microbleeds—as a selective surrogate marker of hemorrhagic complication. Stroke occurrence (ischemic or hemorrhagic) and the progression of functional, cognitive, and motor status will be evaluated as secondary outcomes. Circulating biomarkers may further improve predictive potentials. Results: Starting from September 2017, 194 patients (mean age 78.1 ± 6.7, range 65–97; 61% males) were enrolled. The type of AF was paroxysmal in 93 patients (48%), and persistent or permanent in the remaining patients. Concerning the type of oral anticoagulant, 57 patients (29%) were on vitamin K antagonists, and 137 (71%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI are ongoing. Conclusions: The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in AF, and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.

scholarly journals Dual Antiplatelet Therapy in Secondary Prevention of Ischemic Stroke: A Ghost from the Past or a New Frontier?

2010 ◽  
Vol 2010 ◽  
pp. 1-8
Author(s):  
Clotilde Balucani ◽  
Kristian Barlinn ◽  
Zeljko Zivanovic ◽  
Lucilla Parnetti ◽  
Mauro Silvestrini ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Secondary Prevention ◽  
Extended Release ◽  
Standard Of Care ◽  
Antiplatelet Agents ◽  
Minor Stroke ◽  
Early Management ◽  
New Frontier ◽  
Ischemic Events

With majority of ischemic strokes attributable to atherothrombosis and many being predictable after transient ischemic attacks (TIA), the role of early secondary prevention with antiplatelet agents is under renewed investigation. Prior major clinical trials of various secondary stroke prevention regimens pointed to a greater efficacy of dual antiplatelet agents if initiated early from symptom onset. This paper examines data and rationale behind dual antiplatelet regimens across the completed clinical trials. The safety of dual antiplatelets approach is of concern, but it could be outweighed, at least in early management, by a greater reduction in recurrence of ischemic events since this risk is “front loaded” after minor stroke or TIA. Aspirin monotherapy, though considered standard of care, is compared to aspirin-extended release dipiridamole and its combination with clopidogrel in early-phase completed and efficacy-phase ongoing clinical trials.

scholarly journals The Comparison of Therapeutic Efficacy Between Dabigatran Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation

2021 ◽  
Vol 27 ◽  
pp. 107602962110447
Author(s):  
Hongxia Li ◽  
Lei Zhang ◽  
Ming Xia ◽  
Chi Zhang ◽  
Tingbo Jiang
Keyword(s):  
Atrial Fibrillation ◽  
Dabigatran Etexilate ◽  
Oral Anticoagulants ◽  
International Normalized Ratio ◽  
Thrombin Time ◽  
Nonvalvular Atrial Fibrillation ◽  
Coagulation Assays ◽  
Warfarin Group ◽  
Dose Warfarin ◽  
Coagulation Status

Background Novel oral anticoagulants and warfarin are widely used for stroke prevention in patients with atrial fibrillation. The anticoagulation status of patients receiving warfarin or rivaroxaban has been studied. In this study, we aimed to evaluate the effect of dabigatran and warfarin on preventing thrombin generation (TG). Methods This retrospective study enrolled 237 nonvalvular atrial fibrillation (NVAF) subjects treated with 110 mg dabigatran etexilate twice daily and 224 NVAF patients received adjusted-dose warfarin (international normalized ratio [INR] of 2 to 3)). Coagulation assays, prothrombin fragment 1  +  2 (F1+2), calibrated automated thrombogram, and thrombin–antithrombin complex (TAT) were detected at the steady state. Results Activated partial thromboplastin time (APTT), antithrombin III activity, fibrinogen, and lag time showed no difference between the two groups. Compared to the dabigatran group, prothrombin time and INR values were higher in the warfarin group (all P < .001). Thrombin time, endogenous thrombin potential, peak TG (Cmax), F1+2, and TAT were lower in the warfarin group. The inhibition of TG was still stronger in the warfarin group when the patients were divided into subgroups. Conclusion Conventional coagulation assays are suboptimal for assessing the coagulation status of dabigatran. TG could be used as supplementary assays to evaluate the anticoagulation effect of oral anticoagulants. Our results suggest that warfarin may inhibit TG more aggressively than dabigatran in patients regardless of age and kidney function.

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