scholarly journals Recurrent Hemorrhagic Transformation of Cardioembolic Stroke in an Elderly Patient: A Case Report and Literature Review

2021 ◽  
Vol 8 (05) ◽  
pp. 01-07
Author(s):  
Wengui Yu
Keyword(s):  
Atrial Fibrillation ◽  
Case Report ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Anticoagulation Therapy ◽  
Hemorrhagic Transformation ◽  
Cardioembolic Stroke ◽  
Current Evidence ◽  
Amyloid Angiopathy ◽  
Secondary Stroke Prevention

Proper therapy for secondary stroke prevention is crucial in the management of cardioembolic stroke. Although oral anticoagulants were the superior strategy for patients with atrial fibrillation and stroke per current evidence, many patients with cardioembolic stroke were prescribed with antiplatelet therapy due to concern for the risk of bleeding from anticoagulation therapy. We presented a case of an 84-years-old male patient who had sudden-onset left hemiparesis from cardioembolic stroke. Past medical history was significant for paroxysmal atrial fibrillation, hypertension and uncontrolled diabetes. Severe white matter hyperintensity (WMH) was identified with the brain imaging. The local hospital initiated antiplatelet therapy with Aspirin 100 mg daily for secondary stroke prevention. Subsequently he was found to have recurrent asymptomatic hemorrhagic transformation involving each of the infarctions. The case report highlighted that severe WMH and possible cerebral amyloid angiopathy could be a risk factor of hemorrhagic transformation and antiplatelet therapy should be used prudently in such condition.

scholarly journals Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011–2016

BMJ Open ◽  
2019 ◽  
Vol 9 (4) ◽  
pp. e026645 ◽  
Author(s):  
Géric Maura ◽  
Cécile Billionnet ◽  
Jérôme Drouin ◽  
Alain Weill ◽  
Anke Neumann ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Antiplatelet Therapy ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Vitamin K Antagonist ◽  
Secondary Outcome ◽  
Patterns Of Use

ObjectivesTo describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France.Design(i) Repeated cross-sectional study and (ii) population-based cohort study.SettingFrench national healthcare databases (50 million beneficiaries).Participants(i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015–2016.Primary and secondary outcome measures(i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF.ResultsBetween 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (−22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015–2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing.ConclusionsOAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.

New opportunities to optimize antithrombotic therapy for secondary stroke prevention

2019 ◽  
Vol 14 (3) ◽  
pp. 220-222 ◽  
Author(s):  
Anthony S Kim ◽  
J Donald Easton
Keyword(s):  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Antiplatelet Therapy ◽  
Transient Ischaemic Attack ◽  
Stroke Prevention ◽  
Dual Antiplatelet Therapy ◽  
Secondary Stroke Prevention ◽  
Short Term ◽  
Major Hemorrhage ◽  
Ischaemic Attack

Stroke symptoms can be unsettling, even when symptoms resolve, but focusing on stroke prevention can be empowering provided that effective interventions for appropriate patient populations are available. Current options include interventions for symptomatic carotid artery stenosis, anticoagulation for atrial fibrillation, high-dose statins, new oral anticoagulants, new developments in atrial fibrillation detection, and new therapeutics are in development. For antiplatelet therapy, aspirin monotherapy is effective but dual antiplatelet therapy with the combination of aspirin and clopidogrel increases hemorrhage risks over the long term that outweigh potential benefits. In the short term though, both the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) and Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trials have shown a benefit of short-term dual-antiplatelet therapy, though the increased major hemorrhage risk seen in POINT could justify applying dual-antiplatelet therapy to just the first 21 days. Furthermore, since clopidogrel is a prodrug that must be metabolized to have antiplatelet activity, it is not surprising that the treatment effect in CHANCE was limited to patients who were not carriers of loss-of-function alleles for clopidogrel metabolism. Ticagrelor, an antiplatelet agent which failed to meet its primary endpoint as monotherapy compared to aspirin in the Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) trial, is currently being tested as combination therapy with aspirin compared to aspirin alone in Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death (THALES). These developments along with improvements to the infrastructure to perform rapid evaluations and to apply intensive secondary stroke prevention interventions hold continued promise for the future.

Abstract 3818: Reasons To Withhold Anticoagulation In Atrial Fibrillation Subjects After Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Terri E Kiernan ◽  
Jesse D Coull ◽  
Nadine Lendzion ◽  
Joyce Lee-Iannotti ◽  
Dan J Capampangan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Functional Status ◽  
Antiplatelet Therapy ◽  
Terminal Illness ◽  
Recurrent Stroke ◽  
Anticoagulation Therapy ◽  
Cardioembolic Stroke ◽  
Discharge Disposition ◽  
Acute Rehabilitation ◽  
To Receive

Background: Atrial fibrillation (AF) is an important modifiable and independent risk factor for stroke. AF is associated with 2-4% annual risk for first time stroke and about 8% annually for recurrent stroke. Anticoagulant therapy reduces the risk by 60%, while the relative risk reduction (RRR) obtained from antiplatelet therapy is only 20%. The effect is more robust for secondary than for primary prevention. Risk stratification schemes are utilized to assess an individual’s risk of future stroke and to determine the optimal antithrombotic or anticoagulation regimen for stroke prevention. Despite Warfarin’s superiority over antiplatelet therapy to reduce the risk of AF related systemic embolism, Warfarin is largely underutilized. The aim of this study was to determine the frequency and reasons behind withholding anticoagulation in patient with AF related cardioembolic stroke in our institution. Method: We extracted patients from our Get With The Guideline’s (GWTG) database who were admitted to Mayo Clinic AZ between January 2004 and December 2009. Two authors (TK and NL) independently identified all patients with the diagnosis of atrial fibrillation who were not prescribed Warfarin therapy upon discharge, then reviewed to identify the reason(s) why anticoagulation was not initiated. Factors such as discharge disposition (home, acute rehabilitation, long term nursing facility, hospice, other) and functional status (able to ambulate independently, with assistance, unable to ambulate, or not documented) were also assessed to help support the decision process. Results: From a total of 1295 patients, 305 with AF were identified. Patients who expired 48 (3.7%) from un-related causes were excluded. Of the 257 patients, 206 (80.2%) were anticoagulated and 51 (19.8%) were not anticoagulated. We found that in the anticoagulated group, patients discharged home were more likely to receive anticoagulation (89.2%), followed by those discharged to acute rehabilitation and skilled nursing facilities (77%). Those discharged to hospice were the least likely to receive anticoagulation (6.4%). In addition, patients with greater functional ability were also more likely to receive anticoagulation (independent 89.8%, vs. assisted 76.7%, vs. non-ambulatory 33.3%; p<0.0001). Reasons to withhold anticoagulation therapy at discharge included terminal illness/comfort measures only (40.0%); risk/discomfort due to bleeding (24%); risk of falls (13.0%); and patient refusal (9.0%). Discussion: Based on the results, we conclude that functional status and disposition at discharge are significant factors influencing the decision to anticoagulate after cardioembolic stroke attributed to AF.

scholarly journals Combined Omic Analyzes of Cerebral Thrombi: A New Molecular Approach to Identify Cardioembolic Stroke Origin

Stroke ◽  
2021 ◽  
Author(s):  
Laurent Suissa ◽  
Jean-Marie Guigonis ◽  
Fanny Graslin ◽  
Emmanuelle Robinet-Borgomano ◽  
Yves Chau ◽  
...  
Keyword(s):  
Stroke Prevention ◽  
Small Vessel Disease ◽  
Cardioembolic Stroke ◽  
Receiver Operating Characteristics ◽  
Secondary Stroke Prevention ◽  
Molecular Approach ◽  
Operating Characteristics ◽  
Cardiac Pathology ◽  
Molecular Features ◽  
Receiver Operating

Background and Purpose: The diagnosis of cardioembolic stroke can be challenging for patient management in secondary stroke prevention, particularly in the case of covert paroxysmal atrial fibrillation. The molecular composition of a cerebral thrombus is related to its origin. Therefore, proteomic and metabolomic analyses of the retrieved thrombotic material should allow the identification of biomarkers or signatures to improve the etiological diagnosis of stroke. Methods: In this pilot study, the proteome and metabolome of cerebral thrombi from atherothrombotic and cardioembolic stroke patients were studied according to ASCOD phenotyping (A: atherosclerosis; S: small-vessel disease; C: cardiac pathology; O: other causes; D: dissection), with the highest causality grade, from the ThrombiOMIC cohort (consecutive patients with stroke recanalized by mechanical thrombectomy in an acute phase). Proteomic and metabolomic results were used separately or combined, and the obtained omic signatures were compared with classical cardioembolic stroke predictors using pairwise comparisons of the area under receiver operating characteristics. Results: Among 59 patients of the ThrombiOMIC cohort, 34 patients with stroke showed a cardioembolic phenotype and 7 had an atherothrombotic phenotype. Two thousand four hundred fifty-six proteins and 5019 molecular features of the cerebral thrombi were identified using untargeted proteomic and metabolomic approaches, respectively. Area under receiver operating characteristics to predict the cardioembolic origin of stroke were calculated using the proteomic results (0.945 [95% CI, 0.871–1]), the metabolomic results (0.836 [95% CI, 0.714–0.958]), and combined signatures (0.996 [95% CI, 0.984–1]). The diagnostic performance of the combined signatures was significantly higher than that of classical predictors such as the plasmatic BNP (B-type natriuretic peptide) level (area under receiver operating characteristics, 0.803 [95% CI, 0.629–0.976]). Conclusions: The combined proteomic and metabolomic analyses of retrieved cerebral thrombi is a very promising molecular approach to predict the cardioembolic cause of stroke and to improve secondary stroke prevention strategies.

scholarly journals National Assessment of Warfarin Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 129 (13) ◽  
pp. 1407-1414 ◽  
Author(s):  
Jeffrey S. Dlott ◽  
Roberta A. George ◽  
Xiaohua Huang ◽  
Mouneer Odeh ◽  
Harvey W. Kaufman ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Anticoagulation Therapy ◽  
National Assessment

Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ying Xian ◽  
Peter Shrader ◽  
Eric Smith ◽  
Gregg C Fonarow ◽  
Deepak L Bhatt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Patient Characteristics ◽  
Minor Stroke ◽  
Secondary Stroke Prevention ◽  
Class Iii ◽  
Prescription Patterns ◽  
Class Iib ◽  
Over Time

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit >> risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p<0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p<0.001) and those with NIHSS>3 (18.7%, 22.8%, 28.3%, and 28.3%, p<0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS>3, where the risk-benefit ratio of DAPT remains to be established.

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