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1. Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Author

Paciaroni, M. Angelini, F. Agnelli, G. Tsivgoulis, G. Furie, K.L. Tadi, P. Becattini, C. Falocci, N. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. Altavilla, R. D’Amore, C. Mosconi, M.G. Cimini, L.A. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Bandini, F. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Silvestrelli, G. Ciccone, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. Lodovici, M.L.D. Bono, G. Rueckert, C. Baldi, A. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Sette, M.D. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel Pd-Mer, P. Vanacker, P. Barlinn, K. Pallesen, L.P. Kepplinger, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Yaghi, S. Caso, V. and Paciaroni, M. Angelini, F. Agnelli, G. Tsivgoulis, G. Furie, K.L. Tadi, P. Becattini, C. Falocci, N. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. Altavilla, R. D’Amore, C. Mosconi, M.G. Cimini, L.A. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Bandini, F. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Silvestrelli, G. Ciccone, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. Lodovici, M.L.D. Bono, G. Rueckert, C. Baldi, A. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Sette, M.D. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel Pd-Mer, P. Vanacker, P. Barlinn, K. Pallesen, L.P. Kepplinger, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Yaghi, S. Caso, V.

Abstract

Background: The relationship between different patterns of atrial fibrillation and early recurrence after an acute ischaemic stroke is unclear. Purpose: In a prospective cohort study, we evaluated the rates of early ischaemic recurrence after an acute ischaemic stroke in patients with paroxysmal atrial fibrillation or sustained atrial fibrillation which included persistent and permanent atrial fibrillation. Methods: In patients with acute ischaemic stroke, atrial fibrillation was categorised as paroxysmal atrial fibrillation or sustained atrial fibrillation. Ischaemic recurrences were the composite of ischaemic stroke, transient ischaemic attack and symptomatic systemic embolism occurring within 90 days from acute index stroke. Results: A total of 2150 patients (1155 females, 53.7%) were enrolled: 930 (43.3%) had paroxysmal atrial fibrillation and 1220 (56.7%) sustained atrial fibrillation. During the 90-day follow-up, 111 ischaemic recurrences were observed in 107 patients: 31 in patients with paroxysmal atrial fibrillation (3.3%) and 76 with sustained atrial fibrillation (6.2%) (hazard ratio (HR) 1.86 (95% CI 1.24–2.81)). Patients with sustained atrial fibrillation were on average older, more likely to have diabetes mellitus, hypertension, history of stroke/ transient ischaemic attack, congestive heart failure, atrial enlargement, high baseline NIHSS-score and implanted pacemaker. After adjustment by Cox proportional hazard model, sustained atrial fibrillation was not associated with early ischaemic recurrences (adjusted HR 1.23 (95% CI 0.74–2.04)). Conclusions: After acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. After adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, thus suggesting that the risk profile associated with atrial fibrillation, rather than its patt

Published
2019

2. Causes and Risk Factors of Cerebral Ischemic Events in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention: The RENo Study

Author

Paciaroni, M. Agnelli, G. Caso, V. Silvestrelli, G. Seiffge, D.J. Engelter, S. De Marchis, G.M. Polymeris, A. Zedde, M.L. Yaghi, S. Michel, P. Eskandari, A. Antonenko, K. Sohn, S.-I. Cappellari, M. Tassinari, T. Tassi, R. Masotti, L. Katsanos, A.H. Giannopoulos, S. Acciarresi, M. Alberti, A. Venti, M. Mosconi, M.G. Vedovati, M.C. Pierini, P. Giustozzi, M. Lotti, E.M. Ntaios, G. Kargiotis, O. Monaco, S. Lochner, P. Bandini, F. Liantinioti, C. Palaiodimou, L. Abdul-Rahim, A.H. Lees, K. Mancuso, M. Pantoni, L. Rosa, S. Bertora, P. Galliazzo, S. Ageno, W. Toso, E. Angelini, F. Chiti, A. Orlandi, G. Denti, L. Flomin, Y. Marcheselli, S. Mumoli, N. Rimoldi, A. Verrengia, E. Schirinzi, E. Del Sette, M. Papamichalis, P. Komnos, A. Popovic, N. Zarkov, M. Rocco, A. Diomedi, M. Giorli, E. Ciccone, A. Grory, B.C.M. Furie, K.L. Bonetti, B. Saia, V. Guideri, F. Acampa, M. Martini, G. Grifoni, E. Padroni, M. Karagkiozi, E. Perlepe, K. Makaritsis, K. Mannino, M. MacCarrone, M. Ulivi, L. Giannini, N. Ferrari, E. Pezzini, A. Doronin, B. Volodina, V. Baldi, A. D'Amore, C. Deleu, D. Corea, F. Putaala, J. Santalucia, P. Nardi, K. Risitano, A. Toni, D. Tsivgoulis, G. and Paciaroni, M. Agnelli, G. Caso, V. Silvestrelli, G. Seiffge, D.J. Engelter, S. De Marchis, G.M. Polymeris, A. Zedde, M.L. Yaghi, S. Michel, P. Eskandari, A. Antonenko, K. Sohn, S.-I. Cappellari, M. Tassinari, T. Tassi, R. Masotti, L. Katsanos, A.H. Giannopoulos, S. Acciarresi, M. Alberti, A. Venti, M. Mosconi, M.G. Vedovati, M.C. Pierini, P. Giustozzi, M. Lotti, E.M. Ntaios, G. Kargiotis, O. Monaco, S. Lochner, P. Bandini, F. Liantinioti, C. Palaiodimou, L. Abdul-Rahim, A.H. Lees, K. Mancuso, M. Pantoni, L. Rosa, S. Bertora, P. Galliazzo, S. Ageno, W. Toso, E. Angelini, F. Chiti, A. Orlandi, G. Denti, L. Flomin, Y. Marcheselli, S. Mumoli, N. Rimoldi, A. Verrengia, E. Schirinzi, E. Del Sette, M. Papamichalis, P. Komnos, A. Popovic, N. Zarkov, M. Rocco, A. Diomedi, M. Giorli, E. Ciccone, A. Grory, B.C.M. Furie, K.L. Bonetti, B. Saia, V. Guideri, F. Acampa, M. Martini, G. Grifoni, E. Padroni, M. Karagkiozi, E. Perlepe, K. Makaritsis, K. Mannino, M. MacCarrone, M. Ulivi, L. Giannini, N. Ferrari, E. Pezzini, A. Doronin, B. Volodina, V. Baldi, A. D'Amore, C. Deleu, D. Corea, F. Putaala, J. Santalucia, P. Nardi, K. Risitano, A. Toni, D. Tsivgoulis, G.

Abstract

Background and Purpose-Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non-Vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods-Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results-Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95-5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63-9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83-3.16), and CHA2DS2-VASc score (OR, 1.72 for each point increase; 95% CI, 1.58-1.88) were associated with ischemic events. Among the CHA2DS2-VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33-0.61). Conclusions-In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipid

Published
2019

3. Anticoagulation after Stroke in Patients with Atrial Fibrillation: To Bridge or Not with Low-Molecular-Weight Heparin?

Author

Altavilla, R. Caso, V. Bandini, F. Agnelli, G. Tsivgoulis, G. Yaghi, S. Furie, K.L. Tadi, P. Becattini, C. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Giulia Mosconi, M. Anna Cimini, L. Fusaro, J. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Athanasakis, G. Makaritsis, K. Karagkiozi, E. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Silvestrelli, G. Ciccone, A. Lanari, A. Scoditti, U. Denti, L. Mancuso, M. MacCarrone, M. Ulivi, L. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Barlinn, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Paciaroni, M. and Altavilla, R. Caso, V. Bandini, F. Agnelli, G. Tsivgoulis, G. Yaghi, S. Furie, K.L. Tadi, P. Becattini, C. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Giulia Mosconi, M. Anna Cimini, L. Fusaro, J. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Athanasakis, G. Makaritsis, K. Karagkiozi, E. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Silvestrelli, G. Ciccone, A. Lanari, A. Scoditti, U. Denti, L. Mancuso, M. MacCarrone, M. Ulivi, L. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Barlinn, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Paciaroni, M.

Abstract

Background and Purpose-Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods-We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results-Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients (P=0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4-3.7; P<0.0001), as well as ischemic (odds ratio, 2.2; 95% CI, 1.3-3.9; P=0.005) and hemorrhagic (odds ratio, 2.4; 95% CI, 1.2-4.9; P=0.01) end points separately. Conclusions-Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients. © 2019 American Heart Association, Inc.

Published
2019

4. Hemorrhagic transformation in patients with acute ischemic stroke and atrial fibrillation: Time to initiation of oral anticoagulant therapy and outcomes

Author

Paciaroni, M. Bandini, F. Agnelli, G. Tsivgoulis, G. Yaghi, S. Furie, K.L. Tadi, P. Becattini, C. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D’Amore, C. Mosconi, M.G. Cimini, L.A. Altavilla, R. Volpi, G. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Athanasakis, G. Makaritsis, K. Karagkiozi, E. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Silvestrelli, G. Ciccone, A. Lanari, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Ulivi, L. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Barlinn, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Caso, V. and Paciaroni, M. Bandini, F. Agnelli, G. Tsivgoulis, G. Yaghi, S. Furie, K.L. Tadi, P. Becattini, C. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D’Amore, C. Mosconi, M.G. Cimini, L.A. Altavilla, R. Volpi, G. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Athanasakis, G. Makaritsis, K. Karagkiozi, E. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Silvestrelli, G. Ciccone, A. Lanari, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Ulivi, L. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Barlinn, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Caso, V.

Abstract

Background—In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation (HT). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT, (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results—HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT. Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3-8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0-6.0) of those without HT; 53.1% of patients with HT were deceased or disabled compared with 35.8% of those without HT. On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24-2.35). Conclusions—In patients with HT, anticoagulation was initiated about 12 days later than patients without HT. This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability. © 2018 The Authors.

Published
2018

5. Early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with Non-Vitamin-K oral anticoagulants (RAF-NOACs) Study

Author

Paciaroni, M. Agnelli, G. Falocci, N. Tsivgoulis, G. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Bovi, P. Carletti, M. Cappellari, M. Zedde, M. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Silvestrelli, G. Lanari, A. Ciccone, A. Putaala, J. Tomppo, L. Tatlisumak, T. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Becattini, C. Mosconi, M.G. Cimini, L.A. Soloperto, R. Masotti, L. Vannucchi, V. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Sohn, S.-I. Marcheselli, S. Mumoli, N. De Lodovici, M.L. Bono, G. Furie, K.L. Tadi, P. Yaghi, S. Toni, D. Letteri, F. Tassinari, T. Kargiotis, O. Lotti, E.M. Flomin, Y. Mancuso, M. Maccarrone, M. Giannini, N. Bandini, F. Pezzini, A. Poli, L. Padovani, A. Scoditti, U. Denti, L. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Gourbali, V. Orlandi, G. Giuntini, M. Chiti, A. Giorli, E. Gialdini, G. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Monaco, S. Baronello, M.M. Karapanayiotides, T. Caso, V. and Paciaroni, M. Agnelli, G. Falocci, N. Tsivgoulis, G. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Bovi, P. Carletti, M. Cappellari, M. Zedde, M. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Silvestrelli, G. Lanari, A. Ciccone, A. Putaala, J. Tomppo, L. Tatlisumak, T. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Becattini, C. Mosconi, M.G. Cimini, L.A. Soloperto, R. Masotti, L. Vannucchi, V. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Sohn, S.-I. Marcheselli, S. Mumoli, N. De Lodovici, M.L. Bono, G. Furie, K.L. Tadi, P. Yaghi, S. Toni, D. Letteri, F. Tassinari, T. Kargiotis, O. Lotti, E.M. Flomin, Y. Mancuso, M. Maccarrone, M. Giannini, N. Bandini, F. Pezzini, A. Poli, L. Padovani, A. Scoditti, U. Denti, L. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Gourbali, V. Orlandi, G. Giuntini, M. Chiti, A. Giorli, E. Gialdini, G. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Monaco, S. Baronello, M.M. Karapanayiotides, T. Caso, V.

Abstract

Background--The optimal timing to administer non-vitamin K oral anticoagulants (NOACs) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within90 days)and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention. Methods and Results--Recurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA2DS2-VASc score > 4 and less reduced renal function. Thirty-two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOACs within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated > 14 days after acute stroke. Conclusions--In patients with acute ischemic stroke and atrial fibrillation, treatment with NOACs was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days. © 2017 The Authors.

Published
2017

6. Prediction of Early Recurrent Thromboembolic Event and Major Bleeding in Patients with Acute Stroke and Atrial Fibrillation by a Risk Stratification Schema: The ALESSA Score Study

Author

Paciaroni, M. Agnelli, G. Caso, V. Tsivgoulis, G. Furie, K.L. Tadi, P. Becattini, C. Falocci, N. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Mosconi, M.G. Cimini, L.A. Procopio, A. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Bandini, F. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Silvestrelli, G. Ciccone, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Kepplinger, J. Bodechtel, U. Gerber, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Yaghi, S. and Paciaroni, M. Agnelli, G. Caso, V. Tsivgoulis, G. Furie, K.L. Tadi, P. Becattini, C. Falocci, N. Zedde, M. Abdul-Rahim, A.H. Lees, K.R. Alberti, A. Venti, M. Acciarresi, M. D'Amore, C. Mosconi, M.G. Cimini, L.A. Procopio, A. Bovi, P. Carletti, M. Rigatelli, A. Cappellari, M. Putaala, J. Tomppo, L. Tatlisumak, T. Bandini, F. Marcheselli, S. Pezzini, A. Poli, L. Padovani, A. Masotti, L. Vannucchi, V. Sohn, S.-I. Lorenzini, G. Tassi, R. Guideri, F. Acampa, M. Martini, G. Ntaios, G. Karagkiozi, E. Athanasakis, G. Makaritsis, K. Vadikolias, K. Liantinioti, C. Chondrogianni, M. Mumoli, N. Consoli, D. Galati, F. Sacco, S. Carolei, A. Tiseo, C. Corea, F. Ageno, W. Bellesini, M. Colombo, G. Silvestrelli, G. Ciccone, A. Scoditti, U. Denti, L. Mancuso, M. Maccarrone, M. Orlandi, G. Giannini, N. Gialdini, G. Tassinari, T. De Lodovici, M.L. Bono, G. Rueckert, C. Baldi, A. D'Anna, S. Toni, D. Letteri, F. Giuntini, M. Lotti, E.M. Flomin, Y. Pieroni, A. Kargiotis, O. Karapanayiotides, T. Monaco, S. Baronello, M.M. Csiba, L. Szabó, L. Chiti, A. Giorli, E. Del Sette, M. Imberti, D. Zabzuni, D. Doronin, B. Volodina, V. Michel, P. Vanacker, P. Barlinn, K. Pallesen, L.-P. Kepplinger, J. Bodechtel, U. Gerber, J. Deleu, D. Melikyan, G. Ibrahim, F. Akhtar, N. Gourbali, V. Yaghi, S.

Abstract

Background and Purposes - This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. Methods - The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00-1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08-2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30-1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632-0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493-0.678; P=0.10) for major bleedings. Results - The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529-0.763; P=0.009) for ischemic outcome events and 0.407 (0.275-0.540; P=0.14) for hemorrhagic outcome events. Conclusions - In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings. © 2017 American Heart Association, Inc.

Published
2017

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