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Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation

Thomas R Meinel, Mattia Branca, Gian Marco De Marchis, Krassen Nedeltchev, Timo Kahles, Leo Bonati, Marcel Arnold, Mirjam R Heldner, Simon Jung, Emmanuel Carrera, Elisabeth Dirren, Patrik Michel, Davide Strambo, Carlo W Cereda, Giovanni Bianco, Georg Kägi, Jochen Vehoff, Mira Katan, Manuel Bolognese, Roland Backhaus, Stephan Salmen, Sylvan Albert, Friedrich Medlin, Christian Berger, Ludwig Schelosky, Susanne Renaud, Julien Niederhauser, Christophe Bonvin, Michael Schaerer, Marie-Luise Mono, Biljana Rodic, Alexander A Tarnutzer, Pasquale Mordasini, Jan Gralla, Johannes Kaesmacher, Stefan Engelter, Urs Fischer, David J Seiffge & Investigators Of The Swiss Stroke Registry

abstract

OBJECTIVE
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.

METHODS
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.

RESULTS
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).

INTERPRETATION
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.
   
citation Meinel T R, Branca M, De Marchis G M, Nedeltchev K, Kahles T, Bonati L, Arnold M, Heldner M R, Jung S, Carrera E, Dirren E, Michel P, Strambo D, Cereda C W, Bianco G, Kägi G, Vehoff J, Katan M, Bolognese M, Backhaus R, Salmen S, Albert S, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Schaerer M, Mono M L, Rodic B, Tarnutzer A A, Mordasini P, Gralla J, Kaesmacher J, Engelter S, Fischer U, Seiffge D J, Investigators Of The Swiss Stroke Registry . Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol 2020;.
   
type journal paper/review (English)
date of publishing 30-09-2020
journal title Ann Neurol
ISSN electronic 1531-8249
PubMed 32996627
DOI 10.1002/ana.25917