Cano L M, Cardona P, Quesada H, Lara B, Rubio F
Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
Neurologia. 2016 Jul-Aug;31(6):395-400. doi: 10.1016/j.nrl.2014.09.010. Epub 2014 Dec 16.
Cardioembolic stroke is associated with poorer outcomes. Prevention is based on oral anticoagulant (OAC) therapy. Haemorrhage is the main complication of OACs, which are sometimes ineffective.
We retrospectively reviewed 1014 consecutive patients who suffered an ischaemic stroke between 2011 and 2013, analysing those who were receiving OAC treatment at stroke onset (107 patients in total) with special attention to aetiology, outcomes, and INR value in the acute phase.
The mean age (SD) was 71.9 (10) years. Patients had been treated with OACs for 5.9 (5.5) years; 98.1% of them were being treated for heart disease. INR was <2 in 77 patients (72%), and 30 patients (28%) had an INR≥2. Nine patients (8.4%) had INR values within the therapeutic range. According to TOAST classification criteria, 88.8% of strokes were cardioembolic and 1.9% were atherothrombotic. Anticoagulation therapy was discontinued in 48 patients (44.9%) due to haemorrhagic transformation (24 patients), extensive infarction (23), or endarterectomy (1). Therapy was resumed in 24 patients (50%) after a mean lapse of 36 days. This was not possible in the remaining patients because of death or severe sequelae. New OACs (NOACs) were prescribed to 9 patients (18.7% of all potential candidates). At 3 months, patients with INR>1.7 in the acute phase exhibited better outcomes than patients with INR≤1.7 (mRS 0-2 in 62% vs 30.8%; death in 10% vs 38.4%; P=.0004).
Some patients taking OACs suffer ischaemic strokes that are usually cardioembolic, especially if INR is below the therapeutic range. OACs can be resumed without complications, and NOACs are still underused. Despite cases in which treatment is ineffective, outcomes are better when INR is above 1.7 at stroke onset.
心源性栓塞性卒中与较差的预后相关。预防措施基于口服抗凝剂（OAC）治疗。出血是OAC治疗的主要并发症，且OAC有时无效。
我们回顾性分析了2011年至2013年间连续发生缺血性卒中的1014例患者，对卒中发作时接受OAC治疗的患者（共107例）进行分析，特别关注病因、预后以及急性期的国际标准化比值（INR）值。
平均年龄（标准差）为71.9（10）岁。患者接受OAC治疗的时间为5.9（5.5）年；其中98.1%的患者因心脏病接受治疗。77例患者（72%）的INR<2，30例患者（28%）的INR≥2。9例患者（8.4%）的INR值在治疗范围内。根据TOAST分类标准，88.8%的卒中为心源性栓塞性，1.9%为动脉粥样硬化血栓形成性。48例患者（44.9%）因出血转化（24例）、大面积梗死（23例）或动脉内膜切除术（1例）而停用抗凝治疗。平均36天后，24例患者（50%）恢复治疗。其余患者因死亡或严重后遗症而无法恢复治疗。9例患者（占所有潜在适用患者的18.7%）开始使用新型OAC（NOAC）。在3个月时，急性期INR>1.7的患者比INR≤1.7的患者预后更好（改良Rankin量表评分0 - 2分的比例分别为62%和30.8%；死亡率分别为10%和38.4%；P = 0.0004）。
一些服用OAC的患者发生缺血性卒中，通常为心源性栓塞性，尤其是当INR低于治疗范围时。OAC可在无并发症的情况下恢复使用，且NOAC的使用仍然不足。尽管存在治疗无效的情况，但卒中发作时INR高于1.7时预后更好。
