From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany.
Transfusion and Haemostaseology Department (E.F.S.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany.
Stroke. 2019 Apr;50(4):873-879. doi: 10.1161/STROKEAHA.118.023877.
Background and Purpose- In patients with ischemic stroke on therapy with vitamin K antagonists, stroke severity and clinical course are affected by the quality of anticoagulation at the time of stroke onset, but clinical data for patients using direct oral anticoagulants (DOACs) are limited. Methods- Data from our registry including all patients admitted with acute cerebral ischemia while taking oral anticoagulants for atrial fibrillation between November 2014 and October 2017 were investigated. The activity of vitamin K antagonists was assessed using the international normalized ratio on admission and categorized according to a threshold of 1.7. DOAC plasma levels were measured using the calibrated Xa-activity (apixaban, rivaroxaban, and edoxaban) or the Hemoclot-assay (dabigatran) and categorized into low (<50 ng/mL), intermediate (50-100 ng/mL), or high (>100 ng/mL). Primary objective was the association between anticoagulant activity and clinical and imaging characteristics. Results- Four hundred sixty patients were included (49% on vitamin K antagonists and 51% on DOAC). Patients on vitamin K antagonists with low international normalized ratio values had higher scores on the National Institutes of Health Stroke Scale and a higher risk of large vessel occlusion on admission. For patients on DOAC, plasma levels were available in 75.6% and found to be low in 49 (27.7%), intermediate in 41 (23.2%), and high in 87 patients (49.2%). Low plasma levels were associated with higher National Institutes of Health Stroke Scale scores on admission (low: 8 [interquartile range, 3-15] versus intermediate: 4 [1-11] versus high: 3 [0-8]; P<0.001) and higher risk of persisting neurological deficits or cerebral infarction on imaging (85.7% versus 75.6% versus 54.0%; P<0.001). Low DOAC plasma levels were an independent predictor of large vessel occlusion (odds ratio, 3.84 [95% CI, 1.80-8.20]; P=0.001). Conclusions- The activity of anticoagulation measured by specific DOAC plasma levels on admission is associated with stroke severity and presence of large vessel occlusion.
背景与目的-在接受维生素 K 拮抗剂治疗的缺血性脑卒中患者中，脑卒中严重程度和临床病程受卒中发作时抗凝质量的影响，但关于使用直接口服抗凝剂（DOAC）的患者的临床数据有限。方法-本研究纳入了 2014 年 11 月至 2017 年 10 月期间因心房颤动接受口服抗凝剂治疗期间因急性脑缺血而入院的所有患者的登记资料。入院时通过国际标准化比值评估维生素 K 拮抗剂的活性，并根据 1.7 的阈值进行分类。使用校准的 Xa 活性（阿哌沙班、利伐沙班和依度沙班）或 Hemoclot 分析（达比加群）测量 DOAC 血浆水平，并分为低（<50ng/ml）、中（50-100ng/ml）或高（>100ng/ml）。主要目标是抗凝活性与临床和影像学特征之间的关系。结果-共纳入 460 例患者（49%接受维生素 K 拮抗剂治疗，51%接受 DOAC 治疗）。低国际标准化比值的维生素 K 拮抗剂患者 NIHSS 评分较高，入院时大血管闭塞的风险较高。对于 DOAC 患者，75.6%的患者可获得血浆水平，其中 49 例（27.7%）为低水平，41 例（23.2%）为中水平，87 例（49.2%）为高水平。低血浆水平与入院时更高的 NIHSS 评分相关（低水平：8[四分位间距，3-15]，中水平：4[1-11]，高水平：3[0-8]；P<0.001），影像学上持续存在神经功能缺损或脑梗死的风险更高（85.7%比 75.6%比 54.0%；P<0.001）。低 DOAC 血浆水平是大血管闭塞的独立预测因子（优势比，3.84[95%置信区间，1.80-8.20]；P=0.001）。结论-入院时通过特定 DOAC 血浆水平测量的抗凝活性与卒中严重程度和大血管闭塞的存在相关。
