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1. Attica: A Hot Spot for Forest Fires in Greece

Author

Margarita Arianoutsou, George Athanasakis, Dimitrios Kazanis, and Anastasia Christopoulou

Subjects
wildfires, Pinus halepensis, Abies cephalonica, shrublands, Natura 2000 sites, climate change, Physics, QC1-999
Abstract

(1) Background: Forest fires are widespread in Mediterranean-climate regions and are becoming very common in urban and peri-urban areas. (2) Methods: Wildfires in Attica since 1977 are mapped and types of vegetation burned are reported. (3) Results: Fires are becoming larger. During the period of study (1977–2024), 45% of the burned area was covered with Pinus halepensis forests, 1.4% with Abies cephalonica forests, and 18.5% with shrublands. A relatively high percentage of the burned area (BA) affected more than once consisted of pine forests (65%). Ten percent of the total BA lies within the boundaries of the Natura 2000 network, Europe’s most important network of protected areas, of which 38.9% was burned. At the interannual scale, the BA in Attica is negatively correlated with relative humidity, while reduced precipitation may contribute to the expansion of wildfires. (4) Conclusions: Fires are becoming larger over time, with low humidity increasing the higher fire risk. Since the changing climate is expected to create more severe and uncontrollable conditions, mitigation and adaptation measures should be planned and be introduced immediately.

Published
2024
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2. Practical '1-2-3-4-Day' Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study

Author

Shunsuke Kimura, Kazunori Toyoda, Sohei Yoshimura, Kazuo Minematsu, Masahiro Yasaka, Maurizio Paciaroni, David J. Werring, Hiroshi Yamagami, Takehiko Nagao, Shinichi Yoshimura, Alexandros Polymeris, Annaelle Zietz, Stefan T. Engelter, Bernd Kallmünzer, Manuel Cappellari, Tetsuya Chiba, Takeshi Yoshimoto, Masayuki Shiozawa, Takanari Kitazono, Masatoshi Koga, Kenichi Todo, Kazumi Kimura, Yoshiki Yagita, Eisuke Furui, Ryo Itabashi, Tadashi Terasaki, Yoshiaki Shiokawa, Teruyuki Hirano, Kenji Kamiyama, Jyoji Nakagawara, Shunya Takizawa, Kazunari Homma, Satoshi Okuda, Yasushi Okada, Keisuke Tokunaga, Tomoaki Kameda, Kazuomi Kario, Yoshinari Nagakane, Yasuhiro Hasegawa, Hisanao Akiyama, Satoshi Shibuya, Hiroshi Mochizuki, Yasuhiro Ito, Takahiro Nakashima, Hideki Matsuoka, Kazuhiro Takamatsu, Kazutoshi Nishiyama, Shoichiro Sato, Shoji Arihiro, Manabu Inoue, Masahito Takagi, Kanta Tanaka, Kazuyuki Nagatsuka, Takenori Yamaguchi, Yoichiro Hashimoto, Kiyohiro Houkin, Kazuo Kitagawa, Masayasu Matsumoto, Norio Tanahashi, Yasuo Terayama, Shinichiro Uchiyama, Etsuro Mori, Yutaka Furukawa, Takeshi Kimura, Yoshiaki Kumon, Ken Nagata, Shigeru Nogawa, Tomohiro Sakamoto, Toshinori Hirai, Kohsuke Kudo, Makoto Sasaki, Shotai Kobayashi, Toshimitsu Hamasaki, Michela Giustozzi, Monica Acciarresi, Giancarlo Agnelli, Valeria Caso, Fabio Bandini, Georgios Tsivgoulis, Shadi Yaghi, Karen L. Furie, Prasanna Tadi, Cecilia Becattini, Marialuisa Zedde, Azmil H Abdul-Rahim, Kennedy R Lees, Andrea Alberti, Michele Venti, Cataldo D’Amore, Maria Giulia Mosconi, Ludovica Anna Cimini, Paolo Bovi, Monica Carletti, Alberto Rigatelli, Jukka Putaala, Liisa Tomppo, Turgut Tatlisumak, Simona Marcheselli, Alessandro Pezzini, Loris Poli, Alessandro Padovani, Vieri Vannucchi, Sung-Il Sohn, Gianni Lorenzini, Rossana Tassi, Francesca Guideri, Maurizio Acampa, Giuseppe Martini, George Ntaios, George Athanasakis, Konstantinos Makaritsis, Efstathia Karagkiozi, Konstantinos Vadikolias, Chrissoula Liantinioti, Maria Chondrogianni, Nicola Mumoli, Franco Galati, Simona Sacco, Cindy Tiseo, Francesco Corea, Walter Ageno, Marta Bellesini, Giovanna Colombo, Giorgio Silvestrelli, Alfonso Ciccone, Alessia Lanari, Umberto Scoditti, Licia Denti, Michelangelo Mancuso, Miriam Maccarrone, Leonardo Ulivi, Giovanni Orlandi, Nicola Giannini, Tiziana Tassinari, Maria Luisa De Lodovici, Christina Rueckert, Antonio Baldi, Danilo Toni, Federica Letteri, Martina Giuntini, Enrico Maria Lotti, Yuriy Flomin, Alessio Pieroni, Odysseas Kargiotis, Theodore Karapanayiotides, Serena Monaco, Mario Maimone Baronello, Laszló Csiba, Lilla Szabó, Alberto Chiti, Elisa Giorli, Massimo Del Sette, Davide Imberti, Dorjan Zabzuni, Boris Doronin, Vera Volodina, Patrik Michel, Peter Vanacker, Kristian Barlinn, Lars-Peder Pallesen, Jessica Barlinn, Dirk Deleu, Gayane Melikyan, Faisal Ibrahim, Naveed Akhtar, Vanessa Gourbali, Luca Masotti, Adrian Parry-Jones, Chris Patterson, Christopher Price, Abduelbaset Elmarimi, Anthea Parry, Arumug Nallasivam, Azlisham Mohd Nor, Bernard Esis, David Bruce, Christine Roffe, Clare Holmes, David Cohen, David Hargroves, David Mangion, Dinesh Chadha, Djamil Vahidassr, Dulka Manawadu, Elio Giallombardo, Elizabeth Warburton, Enrico Flossman, Gunaratam Gunathilagan, Harald Proschel, Hedley Emsley, Ijaz Anwar, James Okwera, Janet Putterill, Janice O’Connell, John Bamford, John Corrigan, Jon Scott, Jonathan Birns, Karen Kee, Kari Saastamoinen, Kath Pasco, Krishna Dani, Lakshmanan Sekaran, Lillian Choy, Liz Iveson, Maam Mamun, Mahmud Sajid, Martin Cooper, Matthew Burn, Matthew Smith, Michael Power, Michelle Davis, Nigel Smyth, Roland Veltkamp, Pankaj Sharma, Paul Guyler, Paul O’Mahony, Peter Wilkinson, Prabel Datta, Prasanna Aghoram, Rachel Marsh, Robert Luder, Sanjeevikumar Meenakishundaram, Santhosh Subramonian, Simon Leach, Sissi Ispoglou, Sreeman Andole, Timothy England, Aravindakshan Manoj, Frances Harrington, Habib Rehman, Jane Sword, Julie Staals, Karim Mahawish, Kirsty Harkness, Louise Shaw, Michael McCormich, Nikola Sprigg, Syed Mansoor, Vinodh Krishnamurthy, Philippe A Lyrer, Leo H Bonati, David J Seiffge, Christopher Traenka, Nils Peters, Gian Marco De Marchis, Sebastian Thilemann, Nikolaos S Avramiotis, Henrik Gensicke, Lisa Hert, Benjamin Wagner, Fabian Schaub, Louisa Meya, Joachim Fladt, Tolga Dittrich, Urs Fisch, Bruno Bonetti, Giampaolo Tomelleri, Nicola Micheletti, Cecilia Zivelonghi, Andrea Emiliani, Kosmas Macha, Gabriela Siedler, Svenja Stoll, Ruihao Wang, Bastian Volbers, Stefan Schwab, David Haupenthal, and Luise Gaßmann

Subjects
Advanced and Specialized Nursing, acute ischemic stroke, Time Factors, Administration, Oral, Anticoagulants, Hemorrhage, cardioembolism, Hospitals, United States, Brain Ischemia, anticoagulation, atrial fibrillation, stroke prevention, Cohort Studies, Stroke, Treatment Outcome, Ischemic Attack, Transient, Atrial Fibrillation, Humans, Prospective Studies, Neurology (clinical), Cardiology and Cardiovascular Medicine, Ischemic Stroke
Abstract

Background: The “1-3-6-12-day rule” for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity. Methods: The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0–7), moderate (8–15), and severe (≥16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation. Results: In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)—initiating DOACS within 1, 2, 3, and 4 days, respectively—than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27–0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27–0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data. Conclusions: In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation.

Published
2022
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3. Hemorrhagic Transformation in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Time to Initiation of Oral Anticoagulant Therapy and Outcomes

Author

Maurizio Paciaroni, Fabio Bandini, Giancarlo Agnelli, Georgios Tsivgoulis, Shadi Yaghi, Karen L. Furie, Prasanna Tadi, Cecilia Becattini, Marialuisa Zedde, Azmil H. Abdul‐Rahim, Kennedy R. Lees, Andrea Alberti, Michele Venti, Monica Acciarresi, Cataldo D'Amore, Maria Giulia Mosconi, Ludovica Anna Cimini, Riccardo Altavilla, Giacomo Volpi, Paolo Bovi, Monica Carletti, Alberto Rigatelli, Manuel Cappellari, Jukka Putaala, Liisa Tomppo, Turgut Tatlisumak, Simona Marcheselli, Alessandro Pezzini, Loris Poli, Alessandro Padovani, Luca Masotti, Vieri Vannucchi, Sung‐Il Sohn, Gianni Lorenzini, Rossana Tassi, Francesca Guideri, Maurizio Acampa, Giuseppe Martini, George Ntaios, George Athanasakis, Konstantinos Makaritsis, Efstathia Karagkiozi, Konstantinos Vadikolias, Chrissoula Liantinioti, Maria Chondrogianni, Nicola Mumoli, Domenico Consoli, Franco Galati, Simona Sacco, Antonio Carolei, Cindy Tiseo, Francesco Corea, Walter Ageno, Marta Bellesini, Giovanna Colombo, Giorgio Silvestrelli, Alfonso Ciccone, Alessia Lanari, Umberto Scoditti, Licia Denti, Michelangelo Mancuso, Miriam Maccarrone, Leonardo Ulivi, Giovanni Orlandi, Nicola Giannini, Gino Gialdini, Tiziana Tassinari, Maria Luisa De Lodovici, Giorgio Bono, Christina Rueckert, Antonio Baldi, Sebastiano D'Anna, Danilo Toni, Federica Letteri, Martina Giuntini, Enrico Maria Lotti, Yuriy Flomin, Alessio Pieroni, Odysseas Kargiotis, Theodore Karapanayiotides, Serena Monaco, Mario Maimone Baronello, Laszló Csiba, Lilla Szabó, Alberto Chiti, Elisa Giorli, Massimo Del Sette, Davide Imberti, Dorjan Zabzuni, Boris Doronin, Vera Volodina, Patrik Michel, Peter Vanacker, Kristian Barlinn, Lars‐Peder Pallesen, Jessica Barlinn, Dirk Deleu, Gayane Melikyan, Faisal Ibrahim, Naveed Akhtar, Vanessa Gourbali, and Valeria Caso

Subjects
atrial fibrillation, hemorrhagic transformation, stroke, Diseases of the circulatory (Cardiovascular) system, RC666-701
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.

Published
2018
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4. 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

Maurizio Paciaroni, Giancarlo Agnelli, Nicola Falocci, Georgios Tsivgoulis, Kostantinos Vadikolias, Chrysoula Liantinioti, Maria Chondrogianni, Paolo Bovi, Monica Carletti, Manuel Cappellari, Marialuisa Zedde, George Ntaios, Efstathia Karagkiozi, George Athanasakis, Kostantinos Makaritsis, Giorgio Silvestrelli, Alessia Lanari, Alfonso Ciccone, Jukka Putaala, Liisa Tomppo, Turgut Tatlisumak, Azmil H. Abdul‐Rahim, Kennedy R. Lees, Andrea Alberti, Michele Venti, Monica Acciarresi, Cataldo D'Amore, Cecilia Becattini, Maria Giulia Mosconi, Ludovica Anna Cimini, Rossana Soloperto, Luca Masotti, Vieri Vannucchi, Gianni Lorenzini, Rossana Tassi, Francesca Guideri, Maurizio Acampa, Giuseppe Martini, Sung‐Il Sohn, Simona Marcheselli, Nicola Mumoli, Maria Luisa De Lodovici, Giorgio Bono, Karen L. Furie, Prasanna Tadi, Shadi Yaghi, Danilo Toni, Federica Letteri, Tiziana Tassinari, Odysseas Kargiotis, Enrico Maria Lotti, Yuriy Flomin, Michelangelo Mancuso, Miriam Maccarrone, Nicola Giannini, Fabio Bandini, Alessandro Pezzini, Loris Poli, Alessandro Padovani, Umberto Scoditti, Licia Denti, Domenico Consoli, Franco Galati, Simona Sacco, Antonio Carolei, Cindy Tiseo, Vanessa Gourbali, Giovanni Orlandi, Martina Giuntini, Alberto Chiti, Elisa Giorli, Gino Gialdini, Francesco Corea, Walter Ageno, Marta Bellesini, Giovanna Colombo, Serena Monaco, Mario Maimone Baronello, Theodore Karapanayiotides, and Valeria Caso

Subjects
acute stroke, anticoagulants, atrial fibrillation, secondary prevention, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

BackgroundThe 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 (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention. Methods and ResultsRecurrence 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. ConclusionsIn 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.

Published
2017
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5. Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes

Author

Michele Venti, Walter Ageno, Alfonso Ciccone, Luana Gentile, Vanessa Gourbali, Antonio Baldi, Elisa Grifoni, László Csiba, Cataldo D'Amore, Prasanna Tadi, Yuriy Flomin, Rossana Tassi, Sung Il Sohn, Bruno Bonetti, Patrik Michel, Erika Schirinzi, Alessandro Padovani, Cindy Tiseo, Maria Luisa De Lodovici, Odysseas Kargiotis, Konstantinos Vadikolias, Shadi Yaghi, Maurizio Paciaroni, Georgios Tsivgoulis, Enrico Maria Lotti, Manuel Cappellari, Lilla Szabó, Ashraf Eskandari, Federica Letteri, Leonardo Ulivi, Chrissoula Liantinioti, Valeria Caso, Lina Palaiodimou, Dirk Deleu, Jesse Dawson, Licia Denti, Konstantinos Makaritsis, Gianni Lorenzini, Marina Mannino, Monica Acciarresi, Miriam Maccarrone, Nicola Mumoli, Marta Bellesini, Simona Sacco, George Athanasakis, Umberto Scoditti, Maurizio Acampa, Giuseppe Martini, Brian Mac Grory, Alberto Rigatelli, Kristian Barlinn, Vieri Vannucchi, Serena Monaco, Efstathia Karagkiozi, Elisa Giorli, Francesca Guideri, Martina Giuntini, Dorjan Zabzuni, Davide Imberti, Giorgio Silvestrelli, Luca Masotti, Loris Poli, Karen L. Furie, Alessio Pieroni, Marialuisa Zedde, Franco Galati, Andrea Alberti, Giancarlo Agnelli, Jessica Barlinn, Turgut Tatlisumak, Maria Chiara Caselli, Boris Doronin, Liisa Tomppo, Kennedy R. Lees, Mario Maimone Baronello, Maria Giulia Mosconi, Jukka Putaala, Tiziana Tassinari, Azmil H. Abdul-Rahim, Peter Vanacker, Christina Rueckert, Valentina Bogini, Alessandro Pezzini, Francesco Corea, Giovanni Orlandi, Simona Marcheselli, Michela Giustozzi, Theodore Karapanayiotides, Michelangelo Mancuso, George Ntaios, Fabio Bandini, Vera Volodina, Nicola Giannini, Cesare Porta, Danilo Toni, Alberto Chiti, and Massimo Del Sette

Subjects
Severe bleeding, medicine.medical_specialty, Stroke recurrence, Infarction, stroke recurrence, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Original Research Articles, Internal medicine, Ischaemic stroke, Acute stroke, Medicine, atrial fibrillation, In patient, Acute ischemic stroke, business.industry, Atrial fibrillation, medicine.disease, Cardiology, Human medicine, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
Abstract

Introduction The aim of this study in patients with acute posterior ischaemic stroke (PS) and atrial fibrillation (AF) was to evaluate (1) the risks of recurrent ischaemic event and severe bleeding and (2) these risks in relation with oral anticoagulant therapy (OAT) and its timing. Materials and Methods Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of stroke recurrence, transient ischaemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. Results A total of 2470 patients were available for the analysis: 473 (19.1%) with PS and 1997 (80.9%) with AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39–2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16–1.80). Discussion our findings suggest that, when deciding the time to initiate oral anticoagulation, the location of stroke, either anterior or posterior, does not predict the risk of outcome events. Conclusions Patients with PS or AS and AF appear to have similar risks of ischaemic or haemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT.

Published
2020
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6. Anticoagulation After Stroke in Patients With Atrial Fibrillation

Author

Francesca Guideri, Martina Giuntini, Luca Masotti, Sung Il Sohn, László Csiba, Marta Bellesini, Ludovica Anna Cimini, Lars-Peder Pallesen, Michele Venti, Walter Ageno, Efstathia Karagkiozi, Davide Imberti, Leonardo Ulivi, Alessandro Padovani, Giancarlo Agnelli, Giovanni Orlandi, Danilo Toni, Gianni Lorenzini, Alfonso Ciccone, Dirk Deleu, Licia Denti, Federica Letteri, Giorgio Bono, Karen L. Furie, Vieri Vannucchi, Miriam Maccarrone, Cecilia Becattini, Theodore Karapanayiotides, Domenico Consoli, Monica Carletti, Jukka Putaala, Cataldo D'Amore, Nicola Mumoli, Maria Chondrogianni, Alberto Chiti, Peter Vanacker, Marialuisa Zedde, Michelangelo Mancuso, Boris Doronin, Giorgio Silvestrelli, Vanessa Gourbali, Simona Sacco, Manuel Cappellari, Giuseppe Martini, Christina Rueckert, Faisal Ibrahim, George Ntaios, Serena Monaco, Franco Galati, Antonio Carolei, Alessio Pieroni, Dorjan Zabzuni, Simona Marcheselli, Naveed Akhtar, Prasanna Tadi, Loris Poli, Mario Maimone Baronello, Antonio Baldi, Fabio Bandini, Vera Volodina, George Athanasakis, Yuriy Flomin, Chrysoula Liantinioti, Nicola Giannini, Umberto Scoditti, Elisa Giorli, Gayane Melikyan, Alessandro Pezzini, Alessia Lanari, Andrea Alberti, Konstantinos Makaritsis, Cindy Tiseo, Francesco Corea, Rossana Tassi, Georgios Tsivgoulis, Maria Luisa De Lodovici, Enrico Maria Lotti, Odysseas Kargiotis, Jessica Barlinn, Massimo Del Sette, Konstantinos Vadikolias, Paolo Bovi, Kennedy R. Lees, Riccardo Altavilla, Turgut Tatlisumak, Liisa Tomppo, Maurizio Paciaroni, Lilla Szabó, Alberto Rigatelli, Kristian Barlinn, Monica Acciarresi, Patrik Michel, Tiziana Tassinari, Maurizio Acampa, Maria Giulia Mosconi, Shadi Yaghi, Jessica Fusaro, Valeria Caso, Sebastiano D'Anna, Azmil H. Abdul-Rahim, Gino Gialdini, HUS Neurocenter, Department of Neurosciences, and Neurologian yksikkö

Subjects
anticoagulants, medicine.medical_specialty, LEUKOARAIOSIS, ARTERIAL TERRITORIES, 030204 cardiovascular system & hematology, 3124 Neurology and psychiatry, 03 medical and health sciences, 0302 clinical medicine, atrial fibrillation, humans, incidence, secondary prevention, Internal medicine, medicine, In patient, ACUTE ISCHEMIC-STROKE, Stroke, METAANALYSIS, Cerebral Hemorrhage, RISK, Advanced and Specialized Nursing, Secondary prevention, OUTCOMES, Cardioembolic stroke, Heparin, business.industry, Incidence (epidemiology), Low-Molecular-Weight, 3112 Neurosciences, Atrial fibrillation, HUMAN BRAIN, medicine.disease, Anticoagulants, Atrial Fibrillation, Heparin, Low-Molecular-Weight, Humans, Secondary Prevention, 3. Good health, Heparin.low molecular weight, 3121 General medicine, internal medicine and other clinical medicine, Cardiology, Human medicine, HEMORRHAGIC TRANSFORMATION, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, medicine.drug
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 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.

Published
2019
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7. Safety of anticoagulation in patients treated with urgent reperfusion for ischemic stroke related to atrial fibrillation

Author

Antonio Baldi, Licia Denti, Kennedy R. Lees, Nicola Mumoli, Panagiotis Halvatsiotis, Massimo Del Sette, Alberto Chiti, Peter Vanacker, Marta Bellesini, Tiziana Tassinari, Paolo Bovi, Alessandro Padovani, Christina Rueckert, Jessica Barlinn, Dorjan Zabzuni, Cataldo D'Amore, Loris Poli, Maria Luisa De Lodovici, Federica Letteri, Odysseas Kargiotis, Manuel Cappellari, Prasanna Tadi, Turgut Tatlisumak, Cecilia Becattini, Ludovica Anna Cimini, Liisa Tomppo, Yuriy Flomin, Giancarlo Agnelli, Aikaterini Theodorou, Serena Monaco, Elena Ferrari, Rossana Tassi, Monica Acciarresi, Patrik Michel, Alessio Pieroni, Enrico Maria Lotti, Michele Venti, Walter Ageno, Sung Il Sohn, Leonardo Ulivi, Maurizio Paciaroni, Konstantinos Vadikolias, Jukka Putaala, Cindy Tiseo, Valeria Caso, Alessandro Pezzini, Giorgio Silvestrelli, Alfonso Ciccone, Francesco Corea, Lilla Szabó, Francesca Guideri, Martina Giuntini, Gianni Lorenzini, Efstathia Karagkiozi, Davide Imberti, Luca Masotti, Azmil H. Abdul-Rahim, Theodore Karapanayiotides, Alessia Lanari, Andrea Alberti, Simona Marcheselli, Vieri Vannucchi, Giuseppe Martini, Shadi Yaghi, Marialuisa Zedde, Michela Giustozzi, Karen L. Furie, Danilo Toni, Chrissoula Liantinioti, Dirk Deleu, Franco Galati, Elisa Giorli, Monica Carletti, Vanessa Gourbali, Michelangelo Mancuso, George Ntaios, George Athanasakis, Fabio Bandini, Vera Volodina, Nicola Giannini, Umberto Scoditti, Mario Maimone Baronello, Boris Doronin, Simona Sacco, Maria Giulia Mosconi, Georgios Tsivgoulis, László Csiba, Alberto Rigatelli, Kristian Barlinn, Konstantinos Makaritsis, Maurizio Acampa, and Giovanni Orlandi

Subjects
Male, anticoagulants, medicine.medical_specialty, medicine.medical_treatment, Hemorrhage, Brain Ischemia, Dabigatran, Brain ischemia, Internal medicine, 80 and over, medicine, Humans, atrial fibrillation, Prospective Studies, Prospective cohort study, Blood Coagulation, Stroke, Aged, thrombolytic therapy, Aged, 80 and over, Advanced and Specialized Nursing, Rivaroxaban, business.industry, Warfarin, Atrial fibrillation, Thrombolysis, Middle Aged, medicine.disease, secondary prevention, thrombectomy, Anticoagulants, Atrial Fibrillation, Female, Reperfusion, Thrombectomy, Thrombolytic Therapy, Treatment Outcome, Cardiology, Neurology (clinical), Human medicine, Cardiology and Cardiovascular Medicine, business, medicine.drug
Abstract

Background and Purpose: The optimal timing for starting oral anticoagulant after an ischemic stroke related to atrial fibrillation remains a challenge, mainly in patients treated with systemic thrombolysis or mechanical thrombectomy. We aimed at assessing the incidence of early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with thrombolytic therapy and/or thrombectomy, who then received oral anticoagulants for secondary prevention. Methods: We combined the dataset of the RAF and the RAF-NOACs (Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin K Oral Anticoagulants) studies, which were prospective observational studies carried out from January 2012 to March 2014 and April 2014 to June 2016, respectively. We included consecutive patients with acute ischemic stroke and atrial fibrillation treated with either vitamin K antagonists or nonvitamin K oral anticoagulants. Primary outcome was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding within 90 days from the inclusion. Treated-patients were propensity matched to untreated-patients in a 1:1 ratio after stratification by baseline clinical features. Results: A total of 2159 patients were included, 564 (26%) patients received acute reperfusion therapies. After the index event, 505 (90%) patients treated with acute reperfusion therapies and 1287 of 1595 (81%) patients untreated started oral anticoagulation. Timing of starting oral anticoagulant was similar in reperfusion-treated and untreated patients (median 7.5 versus 7.0 days, respectively). At 90 days, the primary study outcome occurred in 37 (7%) patients treated with reperfusion and in 146 (9%) untreated patients (odds ratio, 0.74 [95% CI, 0.50–1.07]). After propensity score matching, risk of primary outcome was comparable between the 2 groups (odds ratio, 1.06 [95% CI, 0.53–2.02]). Conclusions: Acute reperfusion treatment did not influence the risk of early recurrence and major bleeding in patients with atrial fibrillation–related acute ischemic stroke, who started on oral anticoagulant.

Published
2020

8. Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation

Author

David, Seiffge, Gian Marco De Marchis, Masatoshi, Koga, Maurizio, Paciaroni, Duncan, Wilson, Manuel, Cappellari, Kosmas, Macha, 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, Kenichi, Todo, Kazumi, Kimura, Kensaku, Shibazaki, Yoshiki, Yagita, Eisuke, Furui, Ryo, Itabashi, Tadashi, Terasaki, Yoshiaki, Shiokawa, Teruyuki, Hirano, Rieko, Suzuki, Kenji, Kamiyama, Jyoji, Nakagawara, Shunya, Takizawa, Kazunari, Homma, Satoshi, Okuda, Yasushi, Okada, Koichiro, Maeda, Tomoaki, Kameda, Kazuomi, Kario, Yoshinari, Nagakane, Yasuhiro, Hasegawa, Hisanao, Akiyama, Satoshi, Shibuya, Hiroshi, Mochizuki, Yasuhiro, Ito, Takahiro, Nakashima, Hideki, Matsuoka, Kazuhiro, Takamatsu, Kazutoshi, Nishiyama, Kanta, Tanaka, Kaoru, Endo, Tetsuya, Miyagi, Masato, Osaki, Junpei, Kobayashi, Takuya, Okata, Eijiro, Tanaka, Yuki, Sakamoto, Keisuke, Tokunaga, Hotake, Takizawa, Junji, Takasugi, Soichiro, Matsubara, Kyoko, Higashida, Takayuki, Matsuki, Naoto, Kinoshita, Masayuki, Shiozawa, Toshihiro, Ide, Takeshi, Yoshimoto, Daisuke, Ando, Kyohei, Fujita, Masaya, Kumamoto, Teppei, Kamimura, Muneaki, Kikuno, Tadataka, Mizoguchi, Takeo, Sato, Karen, L Furie, Prasanna, Tadi, Cecilia, Becattini, Nicola, Falocci, Marialuisa, Zedde, Azmil, H Abdul-Rahim, Kennedy, R Lees, Cataldo, D’Amore, Maria, G Mosconi, Ludovica, A Cimini, Monica, Carletti, Alberto, Rigatelli, Jukka, Putaala, Liisa, Tomppo, Turgut, Tatlisumak, Fabio, Bandini, Simona, Marcheselli, Alessandro, Pezzini, Loris, Poli, Alessandro, Padovani, Luca, Masotti, Vieri, Vannucchi, Sung-Il, Sohn, Gianni, Lorenzini, Rossana, Tassi, Francesca, Guideri, Maurizio, Acampa, Giuseppe, Martini, George, Ntaios, Efstathia, Karagkiozi, George, Athanasakis, Kostantinos, Makaritsis, Kostantinos, Vadikolias, Chrysoula, Liantinioti, Maria, Chondrogianni, Nicola, Mumoli, Domenico, Consoli, Franco, Galati, Simona, Sacco, Antonio, Carolei, Cindy, Tiseo, Francesco, Corea, Walter, Ageno, Marta, Bellesini, Giorgio, Silvestrelli, Alfonso, Ciccone, Umberto, Scoditti, Licia, Denti, Mancuso, Michelangelo, Miriam, Maccarrone, Orlandi, Giovanni, Nicola, Giannini, Gino, Gialdini, Tiziana, Tassinari, Maria Luisa De Lodovici, Giorgio, Bono, Christina, Rueckert, Antonio, Baldi, Danilo, Toni, Federica, Letteri, Martina, Giuntini, Enrico, M Lotti, Yuriy, Flomin, Alessio, Pieroni, Odysseas, Kargiotis, Theodore, Karapanayiotides, Serena, Monaco, Laszló, Csiba, Lilla, Szabó, Alberto, Chiti, Elisa, Giorli, Massimo Del Sette, Davide, Imberti, Dorjan, Zabzuni, Boris, Doronin, Vera, Volodina, Patrik, Michel, Peter, Vanacker, Kristian, Barlinn, Lars, P Pallesen, Ulf, Bodechtel, Leonardo, Ulivi, Dirk, Deleu, Gayane, Melikyan, Jessica, Bourlinn, Naveed, Akhar, Falsal, Ibrahin, Gourbali, Vanessa, Hawone, Baronello, Lisa, Hert, Nils, Peters, Marina, Maurer, and Martina, Wiegert

Subjects
0301 basic medicine, medicine.medical_specialty, Vascular disease, business.industry, Hazard ratio, Ischemia, 610 Medicine & health, Atrial fibrillation, medicine.disease, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Neurology, Interquartile range, Internal medicine, Heart failure, medicine, Neurology (clinical), Prospective cohort study, business, Stroke, 030217 neurology & neurosurgery, Research Articles, Research Article
Abstract

Objective:\ud It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed.\ud \ud Methods:\ud We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OACprior ) with those without prior oral anticoagulation (OACnaive ). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OACchanged ) with those who continued the same anticoagulation as secondary prevention (OACunchanged ). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine-Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).\ud \ud Results:\ud We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71-84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2-12]). The median CHA2 DS2 -Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) was 5 (IQR = 4-6) and was similar for OACprior (n = 1,195) and OACnaive (n = 4,119, p = 0.103). During 6,128 patient-years of follow-up, 289 patients had AIS (4.7% per year, 95% CI = 4.2-5.3%). OACprior was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2-2.3, p = 0.005). OACchanged (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7-2.1, p = 0.415) compared with OACunchanged (n = 585).\ud \ud Interpretation:\ud Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA2 DS2 -Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high-risk patient group.

Published
2019
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9. Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Author

Karen L. Furie, Franco Galati, Antonio Carolei, Simona Sacco, Naveed Akhtar, Andrea Alberti, Vanessa Gourbali, Elisa Giorli, Federica Letteri, Filippo Angelini, Georgios Tsivgoulis, Simona Marcheselli, L.-P. Pallesen, Nicola Falocci, Serena Monaco, Giovanni Orlandi, Maria Luisa De Lodovici, Maria Giulia Mosconi, Michele Venti, Walter Ageno, Mario Maimone Baronello, László Csiba, Alfonso Ciccone, Odysseas Kargiotis, Kostantinos Vadikolias, Massimo Del Sette, Chrysoula Liantinioti, Maurizio Paciaroni, Valeria Caso, Cecilia Becattini, Danilo Toni, Peter Vanacker, Alessandro Padovani, Azmil H. Abdul-Rahim, Gino Gialdini, Christina Rueckert, Patrik Michel Pd-Mer, Giorgio Silvestrelli, Marialuisa Zedde, Cataldo D'Amore, Sung Il Sohn, Monica Acciarresi, Monica Carletti, George Ntaios, Kennedy R. Lees, Maria Chondrogianni, Gayane Melikyan, Domenico Consoli, Faisal Ibrahim, Francesca Guideri, Martina Giuntini, Alessandro Pezzini, Fabio Bandini, Vera Volodina, Alberto Rigatelli, Kristian Barlinn, Luca Masotti, Licia Denti, Boris Doronin, Tiziana Tassinari, Cindy Tiseo, Dorjan Zabzuni, Alberto Chiti, Francesco Corea, Nicola Giannini, Loris Poli, Nicola Mumoli, Jessica Kepplinger, Maurizio Acampa, Riccardo Altavilla, George Athanasakis, Theodore Karapanayiotides, Antonio Baldi, Prasanna Tadi, Umberto Scoditti, Turgut Tatlisumak, Yuriy Flomin, Rossana Tassi, Michelangelo Mancuso, Liisa Tomppo, Vieri Vannucchi, Efstathia Karagkiozi, Davide Imberti, Enrico Maria Lotti, Alessio Pieroni, Lilla Szabó, Dirk Deleu, Giancarlo Agnelli, Giorgio Bono, Miriam Maccarrone, Jukka Putaala, Giuseppe Martini, Marta Bellesini, Shadi Yaghi, Ludovica Anna Cimini, Gianni Lorenzini, K. Makaritsis, Paolo Bovi, Manuel Cappellari, HUS Neurocenter, Department of Neurosciences, Neurologian yksikkö, and University of Helsinki

Subjects
medicine.medical_specialty, ANTICOAGULATED PATIENTS, anticoagulation, atrial fibrillation, paroxysmal atrial fibrillation, Stroke, stroke recurrence, sustained atrial fibrillation, Early Recurrence, Paroxysmal atrial fibrillation, Stroke recurrence, macromolecular substances, 030204 cardiovascular system & hematology, 3124 Neurology and psychiatry, EVENTS, 03 medical and health sciences, PERSISTENT, 0302 clinical medicine, Original Research Articles, Internal medicine, Ischaemic stroke, medicine, ORAL ANTICOAGULATION, In patient, cardiovascular diseases, Prospective cohort study, OUTCOMES, business.industry, DEATH, 3112 Neurosciences, Atrial fibrillation, medicine.disease, PATTERN, Cardiology, cardiovascular system, Human medicine, Neurology (clinical), HIGHER RISK, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
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 pattern, is determinant for recurrence.

Published
2019

10. Anticoagulation After Stroke in Patients With Atrial Fibrillation

Author

Riccardo, Altavilla, Valeria, Caso, Fabio, Bandini, Giancarlo, Agnelli, Georgios, Tsivgoulis, Shadi, Yaghi, Karen L, Furie, Prasanna, Tadi, Cecilia, Becattini, Marialuisa, Zedde, Azmil H, Abdul-Rahim, Kennedy R, Lees, Andrea, Alberti, Michele, Venti, Monica, Acciarresi, Cataldo, D'Amore, Maria Giulia, Mosconi, Ludovica, Anna Cimini, Jessica, Fusaro, Paolo, Bovi, Monica, Carletti, Alberto, Rigatelli, Manuel, Cappellari, Jukka, Putaala, Liisa, Tomppo, Turgut, Tatlisumak, Simona, Marcheselli, Alessandro, Pezzini, Loris, Poli, Alessandro, Padovani, Luca, Masotti, Vieri, Vannucchi, Sung-Il, Sohn, Gianni, Lorenzini, Rossana, Tassi, Francesca, Guideri, Maurizio, Acampa, Giuseppe, Martini, George, Ntaios, George, Athanasakis, Konstantinos, Makaritsis, Efstathia, Karagkiozi, Konstantinos, Vadikolias, Chrysoula, Liantinioti, Maria, Chondrogianni, Nicola, Mumoli, Domenico, Consoli, Franco, Galati, Simona, Sacco, Antonio, Carolei, Cindy, Tiseo, Francesco, Corea, Walter, Ageno, Marta, Bellesini, Giorgio, Silvestrelli, Alfonso, Ciccone, Alessia, Lanari, Umberto, Scoditti, Licia, Denti, Michelangelo, Mancuso, Miriam, Maccarrone, Leonardo, Ulivi, Giovanni, Orlandi, Nicola, Giannini, Gino, Gialdini, Tiziana, Tassinari, Maria Luisa, De Lodovici, Giorgio, Bono, Christina, Rueckert, Antonio, Baldi, Sebastiano, D'Anna, Danilo, Toni, Federica, Letteri, Martina, Giuntini, Enrico, Maria Lotti, Yuriy, Flomin, Alessio, Pieroni, Odysseas, Kargiotis, Theodore, Karapanayiotides, Serena, Monaco, Mario, Maimone Baronello, Laszló, Csiba, Lilla, Szabó, Alberto, Chiti, Elisa, Giorli, Massimo, Del Sette, Davide, Imberti, Dorjan, Zabzuni, Boris, Doronin, Vera, Volodina, Patrik, Michel, Peter, Vanacker, Kristian, Barlinn, Lars-Peder, Pallesen, Jessica, Barlinn, Dirk, Deleu, Gayane, Melikyan, Faisal, Ibrahim, Naveed, Akhtar, Vanessa, Gourbali, and Maurizio, Paciaroni

Subjects
Stroke, anticoagulants, atrial fibrillation, humans, incidence, secondary prevention, Heparin, Low-Molecular-Weight, Cerebral Hemorrhage
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; P0.0001), 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.

Published
2019

11. High-resolution Earth observation data and spatial analysis for burn severity evaluation and post-fire effects assessment in the Island of Chios, Greece

Author

Andromachi Chatziantoniou, Emmanouil Psomiadis, and George Athanasakis

Subjects
Earth observation, Geography, 010504 meteorology & atmospheric sciences, 0211 other engineering and technologies, High resolution, 02 engineering and technology, 01 natural sciences, 021101 geological & geomatics engineering, 0105 earth and related environmental sciences, Remote sensing
Published
2017
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12. Age- and sex-specific analysis of patients with embolic stroke of undetermined source

Author

Josefa Pérez Lucas, B. Fuentes, Lucia Pertierra, Gregory Y.H. Lip, Sebastián F. Ameriso, Antonio Arauz, Andrés García Pastor, Maia Gómez-Schneider, Fotios Gioulekas, Elisa Cuadrado-Godia, Konstantinos Vemmos, Miguel A Barboza, Turgut Tatlisumak, Jaume Roquer, Ana Rodríguez-Campello, George Ntaios, Fabio Bandini, Vasileios Papavasileiou, Jukka Putaala, Efstathios Manios, Maurizio Paciaroni, Valentina Arnao, Konstantinos Makaritsis, Beatriz Chavarria Cano, Eleni Koroboki, E. Díez-Tejedor, Anastasia Vemmou, Maximiliano A. Hawkes, Ana Maria Iglesias Mohedano, Antonio Gil-Núñez, George Athanasakis, and Valeria Caso

Subjects
Male, medicine.medical_specialty, Multivariate analysis, Kaplan-Meier Estimate, 030204 cardiovascular system & hematology, Article, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Sex Factors, Recurrence, Risk Factors, Internal medicine, medicine, Humans, cardiovascular diseases, Registries, Risk factor, Stroke, Aged, Proportional Hazards Models, Aged, 80 and over, Proportional hazards model, business.industry, Hazard ratio, Age Factors, Atrial fibrillation, Middle Aged, medicine.disease, Confidence interval, Embolic stroke, Europe, Latin America, Intracranial Embolism, Multivariate Analysis, Female, Neurology (clinical), business, 030217 neurology & neurosurgery, Follow-Up Studies
Abstract

Objective:To investigate whether the correlation of age and sex with the risk of recurrence and death seen in patients with previous ischemic stroke is also evident in patients with embolic stroke of undetermined source (ESUS).Methods:We pooled datasets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. We performed Cox regression and Kaplan-Meier product limit analyses to investigate whether age (80 years) and sex were independently associated with the risk for ischemic stroke/TIA recurrence or death.Results:Ischemic stroke/TIA recurrences and deaths per 100 patient-years were 2.46 and 1.01 in patients 80 years old, 3.53 and 3.48 in women, and 4.49 and 3.98 in men, respectively. Female sex was not associated with increased risk for recurrent ischemic stroke/TIA (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.84–1.58) or death (HR 1.35, 95% CI 0.97–1.86). Compared with the group 80-year groups had higher 10-year cumulative probability of recurrent ischemic stroke/TIA (14.0%, 47.9%, and 37.0%, respectively, p < 0.001) and death (6.4%, 40.6%, and 100%, respectively, p < 0.001) and higher risk for recurrent ischemic stroke/TIA (HR 1.90, 95% CI 1.21–2.98 and HR 2.71, 95% CI 1.57–4.70, respectively) and death (HR 4.43, 95% CI 2.32–8.44 and HR 8.01, 95% CI 3.98–16.10, respectively).Conclusions:Age, but not sex, is a strong predictor of stroke recurrence and death in ESUS. The risk is ≈3- and 8-fold higher in patients >80 years compared with those

Published
2017

13. 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

Francesca Guideri, Martina Giuntini, Luca Masotti, Alessandro Padovani, Danilo Toni, Maria Chondrogianni, Monica Carletti, Cecilia Becattini, Dorjan Zabzuni, Loris Poli, Theodore Karapanayiotides, Monica Acciarresi, Antonio Procopio, Giuseppe Martini, Giovanni Orlandi, Maurizio Acampa, Nicola Falocci, Vieri Vannucchi, Valeria Caso, Cindy Tiseo, Enrico Maria Lotti, László Csiba, Giancarlo Agnelli, Michelangelo Mancuso, Giorgio Bono, Lilla Szabó, Antonio Baldi, Serena Monaco, Jukka Putaala, Faisal Ibrahim, Dirk Deleu, Prasanna Tadi, Yuriy Flomin, Miriam Maccarrone, Georgios Tsivgoulis, Kennedy R. Lees, George Ntaios, Massimo Del Sette, Alberto Rigatelli, Kristian Barlinn, Naveed Akhtar, Jessica Kepplinger, Simona Sacco, Fabio Bandini, Vera Volodina, Lars-Peder Pallesen, Rossana Tassi, Odysseas Kargiotis, Peter Vanacker, Tiziana Tassinari, Nicola Giannini, Christina Rueckert, Ulf Bodechtel, Elisa Giorli, Simona Marcheselli, Efstathia Karagkiozi, Davide Imberti, Michele Venti, Walter Ageno, Chrysoula Liantinioti, Kostantinos Vadikolias, Alfonso Ciccone, Federica Letteri, Domenico Consoli, Andrea Alberti, Turgut Tatlisumak, Marialuisa Zedde, Vanessa Gourbali, Alberto Chiti, Manuel Cappellari, Cataldo D'Amore, Alessandro Pezzini, Francesco Corea, Maurizio Paciaroni, Liisa Tomppo, Giorgio Silvestrelli, Gayane Melikyan, Gianni Lorenzini, K. Makaritsis, Paolo Bovi, Marta Bellesini, Patrik Michel, Ludovica Anna Cimini, Alessio Pieroni, Shadi Yaghi, Sebastiano D'Anna, Azmil H. Abdul-Rahim, Gino Gialdini, Licia Denti, Nicola Mumoli, Mario Maimone Baronello, Maria Luisa De Lodovici, Sung Il Sohn, Johannes Gerber, Giovanna Colombo, Boris Doronin, Karen L. Furie, Franco Galati, Antonio Carolei, Maria Giulia Mosconi, George Athanasakis, and Umberto Scoditti

Subjects
Male, medicine.medical_specialty, atrial fibrillation, myocardial infarction, risk stratification, stroke, Hemorrhage, 030204 cardiovascular system & hematology, Risk Assessment, 03 medical and health sciences, 0302 clinical medicine, Recurrence, Internal medicine, Thromboembolism, Atrial Fibrillation, 80 and over, Medicine, Humans, Myocardial infarction, Aged, Aged, 80 and over, Anticoagulants, Female, Ischemic Attack, Transient, Prospective Studies, Stroke, Warfarin, Prospective cohort study, Advanced and Specialized Nursing, business.industry, Ischemic Attack, Transient, Neurology (clinical), Cardiology and Cardiovascular Medicine, atrial fibrillation, myocardial infarction, risk stratification, stroke, Atrial fibrillation, medicine.disease, Cardiology, Observational study, Human medicine, business, Risk assessment, Complication, 030217 neurology & neurosurgery, medicine.drug
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.

Published
2016

14. Risk Stratification for Recurrence and Mortality in Embolic Stroke of Undetermined Source

Author

Efstathios Manios, Antonio Arauz, Josefa Pérez Lucas, George Ntaios, Fabio Bandini, Antonio Gil-Núñez, Maia Gómez-Schneider, Miguel A Barboza, Lucia Pertierra, Konstantinos Makaritsis, Eleni Koroboki, Maximiliano A. Hawkes, Andrés García Pastor, E. Díez-Tejedor, Elisa Cuadrado-Godia, Ana Maria Iglesias Mohedano, Valentina Arnao, George Athanasakis, Gregory Y.H. Lip, Anastasia Vemmou, Valeria Caso, Ana Rodríguez-Campello, Turgut Tatlisumak, Beatriz Chavarria Cano, Jukka Putaala, Konstantinos Vemmos, B. Fuentes, Vasileios Papavasileiou, Eva Giralt-Steinhauer, Sebastián F. Ameriso, and Maurizio Paciaroni

Subjects
Male, medicine.medical_specialty, Stroke recurrence, Embolism, 030204 cardiovascular system & hematology, Risk Assessment, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Sex Factors, Recurrence, Risk Factors, parasitic diseases, Antithrombotic, Medicine, Humans, In patient, Registries, Aged, Advanced and Specialized Nursing, Secondary prevention, business.industry, Age Factors, Middle Aged, Surgery, Embolic stroke, Stroke, Survival Rate, Ischemic Attack, Transient, Risk stratification, Emergency medicine, Hypertension, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
Abstract

Background and Purpose— The risk of stroke recurrence in patients with Embolic Stroke of Undetermined Source (ESUS) is high, and the optimal antithrombotic strategy for secondary prevention is unclear. We investigated whether congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack (TIA; CHADS 2 ) and CHA 2 DS 2 -VASc scores can stratify the long-term risk of ischemic stroke/TIA recurrence and death in ESUS. Methods— We pooled data sets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. Cox regression analyses were performed to investigate if prestroke CHADS 2 and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65–74 years, sex category (CHA 2 DS 2 -VASc) scores were independently associated with the risk of ischemic stroke/TIA recurrence or death. The Kaplan–Meier product limit method was used to estimate the cumulative probability of ischemic stroke/TIA recurrence and death in different strata of the CHADS 2 and CHA 2 DS 2 -VASc scores. Results— One hundred fifty-nine (5.6% per year) ischemic stroke/TIA recurrences and 148 (5.2% per year) deaths occurred in 1095 patients (median age, 68 years) followed-up for a median of 31 months. Compared with CHADS 2 score 0, patients with CHADS 2 score 1 and CHADS 2 score >1 had higher risk of ischemic stroke/TIA recurrence (hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.41–4.00 and HR, 2.72; 95% CI, 1.68–4.40, respectively) and death (HR, 3.58; 95% CI, 1.80–7.12, and HR, 5.45; 95% CI, 2.86–10.40, respectively). Compared with low-risk CHA 2 DS 2 -VASc score, patients with high-risk CHA 2 DS 2 -VASc score had higher risk of ischemic stroke/TIA recurrence (HR, 3.35; 95% CI, 1.94–5.80) and death (HR, 13.0; 95% CI, 4.7–35.4). Conclusions— The risk of recurrent ischemic stroke/TIA and death in ESUS is reliably stratified by CHADS 2 and CHA 2 DS 2 -VASc scores. Compared with the low-risk group, patients in the high-risk CHA 2 DS 2 -VASc group have much higher risk of ischemic stroke recurrence/TIA and death, approximately 3-fold and 13-fold, respectively.

Published
2016

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