David E Thaler1, Robin Ruthazer2, Christian Weimar2, Joaquín Serena2, Heinrich P Mattle2, Krassen Nedeltchev2, Marie-Luise Mono2, Emanuele Di Angelantonio2, Mitchell S V Elkind2, Marco R Di Tullio2, Shunichi Homma2, Patrik Michel2, Bernhard Meier2, Anthony J Furlan2, Jennifer S Lutz2, David M Kent2. 1. From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH. dthaler@tuftsmedicalcenter.org. 2. From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH.
Abstract
OBJECTIVE: We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation. METHODS: The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) "high-risk" echocardiographic features, and (3) neuroradiologic findings. RESULTS: A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use. CONCLUSION: Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.
OBJECTIVE: We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation. METHODS: The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) "high-risk" echocardiographic features, and (3) neuroradiologic findings. RESULTS: A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use. CONCLUSION: Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.
Authors: Karen L Furie; Scott E Kasner; Robert J Adams; Gregory W Albers; Ruth L Bush; Susan C Fagan; Jonathan L Halperin; S Claiborne Johnston; Irene Katzan; Walter N Kernan; Pamela H Mitchell; Bruce Ovbiagele; Yuko Y Palesch; Ralph L Sacco; Lee H Schwamm; Sylvia Wassertheil-Smoller; Tanya N Turan; Deidre Wentworth Journal: Stroke Date: 2010-10-21 Impact factor: 7.914
Authors: David M Kent; Robin Ruthazer; Christian Weimar; Jean-Louis Mas; Joaquín Serena; Shunichi Homma; Emanuele Di Angelantonio; Marco R Di Tullio; Jennifer S Lutz; Mitchell S V Elkind; John Griffith; Cheryl Jaigobin; Heinrich P Mattle; Patrik Michel; Marie-Louise Mono; Krassen Nedeltchev; Federica Papetti; David E Thaler Journal: Neurology Date: 2013-07-17 Impact factor: 9.910
Authors: David E Thaler; Emanuele Di Angelantonio; Marco R Di Tullio; Jennifer S Donovan; John Griffith; Shunichi Homma; Cheryl Jaigobin; Jean-Louis Mas; Heinrich P Mattle; Patrik Michel; Marie-Luise Mono; Krassen Nedeltchev; Federica Papetti; Robin Ruthazer; Joaquín Serena; Christian Weimar; Mitchell S V Elkind; David M Kent Journal: Int J Stroke Date: 2012-08-09 Impact factor: 5.266
Authors: David M Kent; Issa J Dahabreh; Robin Ruthazer; Anthony J Furlan; Christian Weimar; Joaquín Serena; Bernhard Meier; Heinrich P Mattle; Emanuele Di Angelantonio; Maurizio Paciaroni; Herwig Schuchlenz; Shunichi Homma; Jennifer S Lutz; David E Thaler Journal: Eur Heart J Date: 2015-07-03 Impact factor: 29.983