Meinel, Thomas R.; 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; Bolognese, Manuel; Backhaus, Roland; ... (2021). Prior anticoagulation in patients with ischaemic stroke and atrial fibrillation. Annals of neurology, 89(1), pp. 42-53. Wiley-Blackwell 10.1002/ana.25917
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OBJECTIVE
To evaluate in patients with atrial fibrillation (AF) and acute ischaemic stroke the association of prior anticoagulation with vitamin-K antagonists (VKA) or direct oral anticoagulants (DOACs) with stroke severity, intravenous thrombolysis (IVT) utilization, safety of IVT, and 3-months outcomes.
METHODS
Cohort study of consecutive patients (2013-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/MT, symptomatic intracranial hemorrhage (sICH), and favorable outcome (mRS 0-2) at 3 months.
RESULTS
Of 8179 patients (mean[SD]age, 79.8[9.6] years;49%women), 1486(18%) were on VKA treatment, 1634(20%) on DOAC treatment at stroke onset, and 5059 controls. Stroke severity was lower in patients on DOACs (median NIHSS 4,[IQR2-11]) as compared to VKA (6,[2-14]) and controls (7,[3-15], P<0.001; quantile regression: β -2.1, 95%CI -2.6 - -1.7). The IVT-rate in potentially eligible patients was significantly lower in patients on VKA (156/247 (63%);aOR 0.67; 95%CI 0.50-0.90) and particularly in patients on DOACs (69/464 (15%); aOR 0.06; 95%CI 0.05-0.08) as compared to controls (1544/2504 (74%)). sICH after IVT occurred in 3.6%(2.6-4.7%) of controls, 9/195 (4.6%; 1.9-9.2%; aOR 0.93;0.46-1.90) of patients on VKA and 2/65 (3.1%; 0.4-10.8%, aOR 0.56;0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with 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. This article is protected by copyright. All rights reserved.
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