Macha Kosmas, Volbers Bastian, Bobinger Tobias, Kurka Natalia, Breuer Lorenz, Huttner Hagen B, Schwab Stefan, Köhrmann Martin
Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
J Stroke Cerebrovasc Dis. 2016 Sep;25(9):2317-21. doi: 10.1016/j.jstrokecerebrovasdis.2016.06.031. Epub 2016 Jul 19.
Direct oral anticoagulants (DOACs) are increasingly used for secondary prevention of cardioembolic stroke. While DOACs are associated with a long-term reduced risk of intracranial hemorrhage compared to vitamin K antagonists, pivotal trials avoided the very early period after stroke and few data exist on early initiation of DOAC therapy post stroke.
We retrospectively analyzed data from our prospective database of all consecutive transient ischemic attack (TIA) or ischemic stroke patients with atrial fibrillation treated with DOACs during hospital stay. As per our institutional treatment algorithm for patients with cardioembolic ischemia DOACs are started immediately in TIA and minor stroke (group 1), within days 3-5 in patients with infarcts affecting one third or less of the middle cerebral artery, the anterior cerebral artery, or the posterior cerebral artery territories (group 2) as well as in infratentorial stroke (group 3) and after 1-2 weeks in patients with large infarcts (>⅓MCA territory, group 4). We investigated baseline characteristics, time to initiation of DOAC therapy after symptom onset, and hemorrhagic complications.
In 243 included patients, administration of DOAC was initiated 40.5 hours (interquartile range [IQR] 23.0-65.5) after stroke onset in group 1 (n = 41) and after 76.7 hours (IQR 48.0-134.0), 108.4 hours (IQR 67.3-176.4), and 161.8 hours (IQR 153.9-593.8) in groups 2-4 (n = 170, 28, and 4), respectively. Two cases of asymptomatic intracranial hemorrhage (.8%) and 1 case of symptomatic intracranial hemorrhage (.4%) were observed, both in group 2.
No severe safety issues were observed in early initiation of DOACs for secondary prevention after acute stroke in our in-patient cohort.
直接口服抗凝剂（DOACs）越来越多地用于心源性栓塞性卒中的二级预防。与维生素K拮抗剂相比，DOACs与颅内出血的长期风险降低相关，但关键试验避开了卒中后的极早期，关于卒中后早期开始DOAC治疗的数据很少。
我们回顾性分析了来自我们前瞻性数据库的所有在住院期间接受DOACs治疗的连续性短暂性脑缺血发作（TIA）或缺血性卒中合并房颤患者的数据。根据我们针对心源性缺血患者的机构治疗算法，DOACs在TIA和轻度卒中患者中立即开始使用（第1组），在梗死累及大脑中动脉、大脑前动脉或大脑后动脉区域三分之一或更少的患者中在第3 - 5天开始使用（第2组），以及在幕下卒中患者中（第3组），在大面积梗死患者（>⅓大脑中动脉区域，第4组）中在1 - 2周后开始使用。我们调查了基线特征、症状发作后开始DOAC治疗的时间以及出血并发症。
在243例纳入患者中，第1组（n = 41）在卒中发作后40.5小时（四分位间距[IQR] 23.0 - 65.5）开始使用DOAC，第2 - 4组（n = 170、28和4）分别在76.7小时（IQR 48.0 - 134.0）、108.4小时（IQR 67.3 - 176.4）和161.8小时（IQR 153.9 - 593.8）开始使用。观察到2例无症状颅内出血（0.8%）和1例有症状颅内出血（0.4%），均在第2组。
在我们的住院患者队列中，急性卒中后早期开始使用DOACs进行二级预防未观察到严重的安全问题。
