Kosmas Macha1, Bastian Volbers2, Tobias Bobinger2, Natalia Kurka2, Lorenz Breuer2, Hagen B Huttner2, Stefan Schwab2, Martin Köhrmann2. 1. Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany. Electronic address: kosmas.macha@uk-erlangen.de. 2. Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) are increasingly used for secondary prevention of cardioembolic stroke. While DOACs are associated with a long-term reduced risk of intracranial hemorrhage compared to vitamin K antagonists, pivotal trials avoided the very early period after stroke and few data exist on early initiation of DOAC therapy post stroke. METHODS: We retrospectively analyzed data from our prospective database of all consecutive transient ischemic attack (TIA) or ischemic stroke patients with atrial fibrillation treated with DOACs during hospital stay. As per our institutional treatment algorithm for patients with cardioembolic ischemia DOACs are started immediately in TIA and minor stroke (group 1), within days 3-5 in patients with infarcts affecting one third or less of the middle cerebral artery, the anterior cerebral artery, or the posterior cerebral artery territories (group 2) as well as in infratentorial stroke (group 3) and after 1-2 weeks in patients with large infarcts (>⅓MCA territory, group 4). We investigated baseline characteristics, time to initiation of DOAC therapy after symptom onset, and hemorrhagic complications. RESULTS: In 243 included patients, administration of DOAC was initiated 40.5 hours (interquartile range [IQR] 23.0-65.5) after stroke onset in group 1 (n = 41) and after 76.7 hours (IQR 48.0-134.0), 108.4 hours (IQR 67.3-176.4), and 161.8 hours (IQR 153.9-593.8) in groups 2-4 (n = 170, 28, and 4), respectively. Two cases of asymptomatic intracranial hemorrhage (.8%) and 1 case of symptomatic intracranial hemorrhage (.4%) were observed, both in group 2. CONCLUSIONS: No severe safety issues were observed in early initiation of DOACs for secondary prevention after acute stroke in our in-patient cohort.
BACKGROUND: Direct oral anticoagulants (DOACs) are increasingly used for secondary prevention of cardioembolic stroke. While DOACs are associated with a long-term reduced risk of intracranial hemorrhage compared to vitamin K antagonists, pivotal trials avoided the very early period after stroke and few data exist on early initiation of DOAC therapy post stroke. METHODS: We retrospectively analyzed data from our prospective database of all consecutive transient ischemic attack (TIA) or ischemic strokepatients with atrial fibrillation treated with DOACs during hospital stay. As per our institutional treatment algorithm for patients with cardioembolic ischemiaDOACs are started immediately in TIA and minor stroke (group 1), within days 3-5 in patients with infarcts affecting one third or less of the middle cerebral artery, the anterior cerebral artery, or the posterior cerebral artery territories (group 2) as well as in infratentorial stroke (group 3) and after 1-2 weeks in patients with large infarcts (>⅓MCA territory, group 4). We investigated baseline characteristics, time to initiation of DOAC therapy after symptom onset, and hemorrhagic complications. RESULTS: In 243 included patients, administration of DOAC was initiated 40.5 hours (interquartile range [IQR] 23.0-65.5) after stroke onset in group 1 (n = 41) and after 76.7 hours (IQR 48.0-134.0), 108.4 hours (IQR 67.3-176.4), and 161.8 hours (IQR 153.9-593.8) in groups 2-4 (n = 170, 28, and 4), respectively. Two cases of asymptomatic intracranial hemorrhage (.8%) and 1 case of symptomatic intracranial hemorrhage (.4%) were observed, both in group 2. CONCLUSIONS: No severe safety issues were observed in early initiation of DOACs for secondary prevention after acute stroke in our in-patient cohort.
Authors: David J Seiffge; Gian Marco De Marchis; Masatoshi Koga; Maurizio Paciaroni; Duncan Wilson; Manuel Cappellari; Kosmas Macha Md; Georgios Tsivgoulis; Gareth Ambler; Shoji Arihiro; Leo H Bonati; Bruno Bonetti; Bernd Kallmünzer; Keith W Muir; Paolo Bovi; Henrik Gensicke; Manabu Inoue; Stefan Schwab; Shadi Yaghi; Martin M Brown; Philippe Lyrer; Masahito Takagi; Monica Acciarrese; Hans Rolf Jager; Alexandros A Polymeris; Kazunori Toyoda; Michele Venti; Christopher Traenka; Hiroshi Yamagami; Andrea Alberti; Sohei Yoshimura; Valeria Caso; Stefan T Engelter; David J Werring Journal: Ann Neurol Date: 2020-02-12 Impact factor: 10.422
Authors: David J Seiffge; Maurizio Paciaroni; Duncan Wilson; Masatoshi Koga; Kosmas Macha; Manuel Cappellari; Sabine Schaedelin; Clare Shakeshaft; Masahito Takagi; Georgios Tsivgoulis; Bruno Bonetti; Bernd Kallmünzer; Shoji Arihiro; Andrea Alberti; Alexandros A Polymeris; Gareth Ambler; Sohei Yoshimura; Michele Venti; Leo H Bonati; Keith W Muir; Hiroshi Yamagami; Sebastian Thilemann; Riccardo Altavilla; Nils Peters; Manabu Inoue; Tobias Bobinger; Giancarlo Agnelli; Martin M Brown; Shoichiro Sato; Monica Acciarresi; Hans Rolf Jager; Paolo Bovi; Stefan Schwab; Philippe Lyrer; Valeria Caso; Kazunori Toyoda; David J Werring; Stefan T Engelter; Gian Marco De Marchis Journal: Ann Neurol Date: 2019-04-30 Impact factor: 10.422
Authors: Duncan Wilson; Gareth Ambler; Gargi Banerjee; Clare Shakeshaft; Hannah Cohen; Tarek A Yousry; Rustam Al-Shahi Salman; Gregory Y H Lip; Henry Houlden; Martin M Brown; Keith W Muir; Hans Rolf Jäger; David J Werring Journal: J Neurol Neurosurg Psychiatry Date: 2018-11-19 Impact factor: 10.154
Authors: David Z Rose; John N Meriwether; Michael G Fradley; Swetha Renati; Ryan C Martin; Thomas Kasprowicz; Aarti Patel; Maxim Mokin; Ryan Murtagh; Kevin Kip; Andrea C Bozeman; Tara McTigue; Nicholas Hilker; Bonnie Kirby; Natasha Wick; Nhi Tran; W Scott Burgin; Arthur J Labovitz Journal: Front Neurol Date: 2019-09-20 Impact factor: 4.003