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Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation

OBJECTIVE: It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. METHODS: We conducted an individual patient data pooled analysi...

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Autores principales: Seiffge, David J., De Marchis, Gian Marco, Koga, Masatoshi, Paciaroni, Maurizio, Wilson, Duncan, Cappellari, Manuel, Macha, MD, Kosmas, Tsivgoulis, Georgios, Ambler, Gareth, Arihiro, Shoji, Bonati, Leo H., Bonetti, Bruno, Kallmünzer, Bernd, Muir, Keith W., Bovi, Paolo, Gensicke, Henrik, Inoue, Manabu, Schwab, Stefan, Yaghi, Shadi, Brown, Martin M., Lyrer, Philippe, Takagi, Masahito, Acciarrese, Monica, Jager, Hans Rolf, Polymeris, Alexandros A., Toyoda, Kazunori, Venti, Michele, Traenka, Christopher, Yamagami, Hiroshi, Alberti, Andrea, Yoshimura, Sohei, Caso, Valeria, Engelter, Stefan T., Werring, David J.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: John Wiley & Sons, Inc. 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383617/
https://www.ncbi.nlm.nih.gov/pubmed/32052481
http://dx.doi.org/10.1002/ana.25700
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author Seiffge, David J.
De Marchis, Gian Marco
Koga, Masatoshi
Paciaroni, Maurizio
Wilson, Duncan
Cappellari, Manuel
Macha, MD, Kosmas
Tsivgoulis, Georgios
Ambler, Gareth
Arihiro, Shoji
Bonati, Leo H.
Bonetti, Bruno
Kallmünzer, Bernd
Muir, Keith W.
Bovi, Paolo
Gensicke, Henrik
Inoue, Manabu
Schwab, Stefan
Yaghi, Shadi
Brown, Martin M.
Lyrer, Philippe
Takagi, Masahito
Acciarrese, Monica
Jager, Hans Rolf
Polymeris, Alexandros A.
Toyoda, Kazunori
Venti, Michele
Traenka, Christopher
Yamagami, Hiroshi
Alberti, Andrea
Yoshimura, Sohei
Caso, Valeria
Engelter, Stefan T.
Werring, David J.
author_facet Seiffge, David J.
De Marchis, Gian Marco
Koga, Masatoshi
Paciaroni, Maurizio
Wilson, Duncan
Cappellari, Manuel
Macha, MD, Kosmas
Tsivgoulis, Georgios
Ambler, Gareth
Arihiro, Shoji
Bonati, Leo H.
Bonetti, Bruno
Kallmünzer, Bernd
Muir, Keith W.
Bovi, Paolo
Gensicke, Henrik
Inoue, Manabu
Schwab, Stefan
Yaghi, Shadi
Brown, Martin M.
Lyrer, Philippe
Takagi, Masahito
Acciarrese, Monica
Jager, Hans Rolf
Polymeris, Alexandros A.
Toyoda, Kazunori
Venti, Michele
Traenka, Christopher
Yamagami, Hiroshi
Alberti, Andrea
Yoshimura, Sohei
Caso, Valeria
Engelter, Stefan T.
Werring, David J.
author_sort Seiffge, David J.
collection PubMed
description OBJECTIVE: It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. METHODS: We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OAC(prior)) with those without prior oral anticoagulation (OAC(naive)). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OAC(changed)) with those who continued the same anticoagulation as secondary prevention (OAC(unchanged)). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine–Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71–84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2–12]). The median CHA(2)DS(2)‐Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65–74 years, sex category) was 5 (IQR = 4–6) and was similar for OAC(prior) (n = 1,195) and OAC(naive) (n = 4,119, p = 0.103). During 6,128 patient‐years of follow‐up, 289 patients had AIS (4.7% per year, 95% CI = 4.2–5.3%). OAC(prior) was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2–2.3, p = 0.005). OAC(changed) (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7–2.1, p = 0.415) compared with OAC(unchanged) (n = 585). INTERPRETATION: Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA(2)DS(2)‐Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high‐risk patient group. ANN NEUROL 2020;87:677–687
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spelling pubmed-73836172020-07-27 Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation Seiffge, David J. De Marchis, Gian Marco Koga, Masatoshi Paciaroni, Maurizio Wilson, Duncan Cappellari, Manuel Macha, MD, Kosmas Tsivgoulis, Georgios Ambler, Gareth Arihiro, Shoji Bonati, Leo H. Bonetti, Bruno Kallmünzer, Bernd Muir, Keith W. Bovi, Paolo Gensicke, Henrik Inoue, Manabu Schwab, Stefan Yaghi, Shadi Brown, Martin M. Lyrer, Philippe Takagi, Masahito Acciarrese, Monica Jager, Hans Rolf Polymeris, Alexandros A. Toyoda, Kazunori Venti, Michele Traenka, Christopher Yamagami, Hiroshi Alberti, Andrea Yoshimura, Sohei Caso, Valeria Engelter, Stefan T. Werring, David J. Ann Neurol Research Articles OBJECTIVE: It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. METHODS: We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OAC(prior)) with those without prior oral anticoagulation (OAC(naive)). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OAC(changed)) with those who continued the same anticoagulation as secondary prevention (OAC(unchanged)). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine–Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71–84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2–12]). The median CHA(2)DS(2)‐Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65–74 years, sex category) was 5 (IQR = 4–6) and was similar for OAC(prior) (n = 1,195) and OAC(naive) (n = 4,119, p = 0.103). During 6,128 patient‐years of follow‐up, 289 patients had AIS (4.7% per year, 95% CI = 4.2–5.3%). OAC(prior) was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2–2.3, p = 0.005). OAC(changed) (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7–2.1, p = 0.415) compared with OAC(unchanged) (n = 585). INTERPRETATION: Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA(2)DS(2)‐Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high‐risk patient group. ANN NEUROL 2020;87:677–687 John Wiley & Sons, Inc. 2020-02-27 2020-05 /pmc/articles/PMC7383617/ /pubmed/32052481 http://dx.doi.org/10.1002/ana.25700 Text en © 2020 The Authors. Annals of Neurology published by Wiley Periodicals, Inc. on behalf of American Neurological Association. This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research Articles
Seiffge, David J.
De Marchis, Gian Marco
Koga, Masatoshi
Paciaroni, Maurizio
Wilson, Duncan
Cappellari, Manuel
Macha, MD, Kosmas
Tsivgoulis, Georgios
Ambler, Gareth
Arihiro, Shoji
Bonati, Leo H.
Bonetti, Bruno
Kallmünzer, Bernd
Muir, Keith W.
Bovi, Paolo
Gensicke, Henrik
Inoue, Manabu
Schwab, Stefan
Yaghi, Shadi
Brown, Martin M.
Lyrer, Philippe
Takagi, Masahito
Acciarrese, Monica
Jager, Hans Rolf
Polymeris, Alexandros A.
Toyoda, Kazunori
Venti, Michele
Traenka, Christopher
Yamagami, Hiroshi
Alberti, Andrea
Yoshimura, Sohei
Caso, Valeria
Engelter, Stefan T.
Werring, David J.
Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title_full Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title_fullStr Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title_full_unstemmed Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title_short Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
title_sort ischemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation
topic Research Articles
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383617/
https://www.ncbi.nlm.nih.gov/pubmed/32052481
http://dx.doi.org/10.1002/ana.25700
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