Internal Medicine II, Stroke Unit and Center of Thromboembolic Diseases, San Giuseppe Hospital, Viale Boccaccio 20, 50053, Empoli, Florence, Italy.
Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy.
J Thromb Thrombolysis. 2019 Feb;47(2):292-300. doi: 10.1007/s11239-018-1775-2.
Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of non valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. In the latest years a lot of real life studies on this topic have been published. The aim of our review was to focus on these. We reviewed the PubMed databases searching articles reporting on DOACs starting time within 2 weeks from AIS onset. We selected fifteen studies, eight with retrospective, six with prospective observational and one with a prospective, open-label, single arm design. Overall, 2920 patients (47.8% females) were included. In twelve studies median or mean age of patients was over 75 years. Mean or median NIHSS ad hospital admission was ≤ 12 in all studies. About one-third of patients (32.4%) received urgent reperfusion by systemic thrombolysis or mechanical thrombectomy. About one-fifth of patients (22.8%) had large infarct size. Median starting time of DOACs was reported in thirteen studies and it ranged from 2 to 8 days. About one-half of patients (45.9%) received a low dose of DOACs. In studies reporting on median or mean CHADS-VASC score, it was ≥ 3 in all. In studies reporting on median or mean HAS-BLED score, it was ≥ 2 in all. Ninety-day follow-up was available for nine studies, overall including about 2200 patients. Incidence of 90-day TIA/stroke recurrence, symptomatic haemorrhagic transformation or intracranial bleeding and all cause mortality was 2.25%, 0.90% and 1.5%, respectively. The real life evidence suggests that early starting of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality.
在非瓣膜性心房颤动（NVAF）相关急性缺血性脑卒中（AIS）的早期阶段，使用直接口服抗凝剂（DOACs）的有力证据不足，因为这类患者被排除在 III 期随机临床试验（RCT）之外，并且正在进行专门的 RCT。近年来，已经发表了许多关于这个主题的真实生活研究。我们的综述旨在关注这些研究。我们在 PubMed 数据库中搜索了报告 DOACs 开始时间在 AIS 发病后 2 周内的文章。我们选择了 15 项研究，其中 8 项为回顾性研究，6 项为前瞻性观察性研究，1 项为前瞻性、开放标签、单臂设计。总的来说，共纳入 2920 例患者（47.8%为女性）。在 12 项研究中，患者的中位或平均年龄超过 75 岁。所有研究中，入院时 NIHSS 评分的中位数或平均值均≤12。约三分之一的患者（32.4%）接受了全身性溶栓或机械取栓的紧急再灌注治疗。约五分之一的患者（22.8%）存在大梗死灶。13 项研究报告了 DOACs 的中位或平均起始时间，范围为 2 至 8 天。约一半的患者（45.9%）接受了 DOACs 的低剂量治疗。在报告中位数或平均值 CHADS-VASC 评分的研究中，所有研究的评分均≥3。在报告中位数或平均值 HAS-BLED 评分的研究中，所有研究的评分均≥2。9 项研究报告了 90 天随访情况，共包括约 2200 例患者。90 天 TIA/卒中复发、症状性出血性转化或颅内出血和全因死亡率的发生率分别为 2.25%、0.90%和 1.5%。真实世界的证据表明，在 NVAF 相关 AIS 患者中早期开始使用 DOACs 是安全的，并且与低复发风险和全因死亡率相关。
