Anticoagulation After Stroke in Patients With Atrial Fibrillation

Author:

Altavilla Riccardo1,Caso Valeria1,Bandini Fabio2,Agnelli Giancarlo1,Tsivgoulis Georgios34,Yaghi Shadi5,Furie Karen L.5,Tadi Prasanna5,Becattini Cecilia1,Zedde Marialuisa5,Abdul-Rahim Azmil H.6,Lees Kennedy R.6,Alberti Andrea1,Venti Michele1,Acciarresi Monica1,D’Amore Cataldo1,Giulia Mosconi Maria1,Anna Cimini Ludovica1,Fusaro Jessica1,Bovi Paolo7,Carletti Monica7,Rigatelli Alberto7,Cappellari Manuel7,Putaala Jukka8,Tomppo Liisa8,Tatlisumak Turgut8910,Marcheselli Simona11,Pezzini Alessandro12,Poli Loris12,Padovani Alessandro12,Masotti Luca13,Vannucchi Vieri13,Sohn Sung-Il14,Lorenzini Gianni15,Tassi Rossana16,Guideri Francesca16,Acampa Maurizio16,Martini Giuseppe16,Ntaios George17,Athanasakis George17,Makaritsis Konstantinos17,Karagkiozi Efstathia17,Vadikolias Konstantinos18,Liantinioti Chrysoula4,Chondrogianni Maria4,Mumoli Nicola19,Consoli Domenico20,Galati Franco20,Sacco Simona21,Carolei Antonio21,Tiseo Cindy21,Corea Francesco22,Ageno Walter23,Bellesini Marta23,Silvestrelli Giorgio24,Ciccone Alfonso24,Lanari Alessia24,Scoditti Umberto25,Denti Licia26,Mancuso Michelangelo27,Maccarrone Miriam27,Ulivi Leonardo27,Orlandi Giovanni2728,Giannini Nicola27,Gialdini Gino27,Tassinari Tiziana29,De Lodovici Maria Luisa30,Bono Giorgio30,Rueckert Christina31,Baldi Antonio32,D’Anna Sebastiano32,Toni Danilo33,Letteri Federica33,Giuntini Martina28,Maria Lotti Enrico34,Flomin Yuriy35,Pieroni Alessio33,Kargiotis Odysseas36,Karapanayiotides Theodore37,Monaco Serena38,Maimone Baronello Mario38,Csiba Laszló39,Szabó Lilla39,Chiti Alberto2740,Giorli Elisa40,Del Sette Massimo4041,Imberti Davide42,Zabzuni Dorjan42,Doronin Boris43,Volodina Vera43,Michel Patrik44,Vanacker Peter45,Barlinn Kristian46,Pallesen Lars-Peder46,Barlinn Jessica46,Deleu Dirk47,Melikyan Gayane47,Ibrahim Faisal47,Akhtar Naveed47,Gourbali Vanessa48,Paciaroni Maurizio1

Affiliation:

1. From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)

2. Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)

3. Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)

4. Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni)

5. Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale–IRCCS, Reggio Emilia, Italy (M.Z.)

6. Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.)

7. SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari)

8. Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T.T.)

9. Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden (T.T.)

10. Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)

11. Neurologia d’urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S.M.)

12. Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani)

13. Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V.V.)

14. Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.I.S.)

15. SC Medicina e Chirurgia d’Accettazione e d’Urgenza, Ospedale Lotti Pontedera, Azienda USL Toscana Nordovest, Pisa, Italy (G.L.)

16. Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini)

17. Department of Medicine, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)

18. Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (K.V.)

19. Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.)

20. Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F.G.)

21. Department of Neurology, University of L’Aquila, Avezzano Hospital, Italy (S.S., A. Carolei, C.T.)

22. UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C.)

23. Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.)

24. S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone, A.L.)

25. Stroke Unit, Neuroscience Department (U.S.), University of Parma, Italy

26. Stroke Unit, Dipartimento Geriatrico Riabilitativo (L.D.), University of Parma, Italy

27. Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)

28. Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.)

29. Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T.)

30. Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L.D.L., G.B.)

31. Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.)

32. Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., S.D.)

33. Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A.P.)

34. U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L.)

35. Stroke and Neurorehabilitation Unit, MC Universal Clinic ‘Oberig’, Kyiv, Ukraine (Y.F.)

36. Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.)

37. 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.)

38. Stroke Unit, Ospedale Civico, Palermo, Italy (S.M., M.M.B.)

39. Stroke Unit, University of Debrecen, Hungary (L.C., L.S.)

40. Stroke Unit, Department of Neurology, Sant’Andrea Hospital, La Spezia, Italy (A.C., E.G., M.D.S.)

41. Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.)

42. Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.)

43. Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)

44. Département des Neurosciences Cliniques, Centre Cérébrovasculaire, Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.)

45. Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Belgium (P.V.)

46. Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.B.)

47. Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.)

48. Department of Neurology, Evangelismos Hospital, Athens (V.G.).

Abstract

Background and Purpose— Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods— We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results— Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients ( P =0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4–3.7; P <0.0001), as well as ischemic (odds ratio, 2.2; 95% CI, 1.3–3.9; P =0.005) and hemorrhagic (odds ratio, 2.4; 95% CI, 1.2–4.9; P =0.01) end points separately. Conclusions— Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Advanced and Specialised Nursing,Cardiology and Cardiovascular Medicine,Clinical Neurology

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