Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation
Journal Paper/Review - Sep 30, 2020
Meinel Thomas R, Albert Sylvan, Medlin Friedrich, Berger Christian, Schelosky Ludwig, Renaud Susanne, Niederhauser Julien, Bonvin Christophe, Schaerer Michael, Mono Marie-Luise, Rodic Biljana, Tarnutzer Alexander A, Mordasini Pasquale, Gralla Jan, Kaesmacher Johannes, Engelter Stefan, Fischer Urs, Seiffge David J, Salmen Stephan, Backhaus Roland, Bolognese Manuel, Branca Mattia, De Marchis Gian Marco, Nedeltchev Krassen, Kahles Timo, Bonati Leo, Arnold Marcel, Heldner Mirjam R, Jung Simon, Carrera Emmanuel, Dirren Elisabeth, Michel Patrik, Strambo Davide, Cereda Carlo W, Bianco Giovanni, Kägi Georg, Vehoff Jochen, Katan Mira, Investigators of the Swiss Stroke Registry
The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes.
This was a cohort study of consecutive patients (2014-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0-2) at 3 months.
Of 8,179 patients (mean [SD] age, 79.8 [9.6] years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, [interquartile range 2-11]) compared with VKA (6, [2-14]) and controls (7, [3-15], p < 0.001; quantile regression: β -2.1, 95% confidence interval [CI] -2.6 to -1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 [63%]; adjusted odds ratio [aOR] 0.67; 95% CI 0.50-0.90) and particularly in patients on DOACs (69 of 464 [15%]; aOR 0.06; 95% CI 0.05-0.08) compared with controls (1,544 of 2,504 [74%]). sICH after IVT occurred in 3.6% (2.6-4.7%) of controls, 9 of 195 (4.6%; 1.9-9.2%; aOR 0.93; 95% CI 0.46-1.90) patients on VKA and 2 of 65 (3.1%; 0.4-10.8%, aOR 0.56; 95% CI 0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3-month outcome (aOR 1.24; 1.01-1.51).
Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2020.