Badi Mohammed K, Vilanilam George K, Gupta Vivek, Barrett Kevin M, Lesser Elizabeth R, Cochuyt Jordan J, Hodge David O, Brott Thomas G, Meschia James F
Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida.
Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida.
J Stroke Cerebrovasc Dis. 2019 Aug;28(8):2159-2167. doi: 10.1016/j.jstrokecerebrovasdis.2019.04.027. Epub 2019 May 15.
Patients with cerebral microbleeds have increased risk of intracranial hemorrhage and ischemic stroke. No trial specifically informs antithrombotic therapy for patients with cerebral microbleeds and atrial fibrillation. We investigated the safety of anticoagulation versus no anticoagulation with regard to cerebrovascular outcomes and mortality.
All consecutive atrial fibrillation patients from 2015 to 2018 with MRI evidence of ≥1 cerebral microbleed at time of imaging were reviewed. Patients were treated with warfarin, direct oral anticoagulants, or neither. Primary outcome was all-cause mortality informed by National Death Registry and the composite of ischemic and hemorrhagic stroke. All statistical tests were 2-sided and significant at P < .05.
The median interval from patient identification until the end of electronic health record surveillance was 9.93 months (interquartile range, 2.83-19.17 months). We identified 308 atrial fibrillation patients with cerebral microbleeds; 128(41.6%) were on warfarin, 88(28.6%) on direct oral anticoagulants, and 92(29.9%) on neither. Over the surveillance interval, 87 deaths, 51 ischemic strokes, and 14 hemorrhagic strokes occurred. The estimated likelihoods of the composite stroke outcome and ischemic stroke only did not differ significantly among the 3 groups. However, patients taking direct oral anticoagulants had a significantly smaller likelihood of all-cause mortality than patients who were not anticoagulated (adjusted hazard ratio: .44[.23, .83], P=.012).
In patients with coprevalent atrial fibrillation and cerebral microbleeds, we did not detect differences in subsequent ischemic stroke, hemorrhagic stroke, or both, comparing warfarin, direct oral anticoagulants, or neither. Patients treated with direct oral anticoagulants had better survival than nonanticoagulated patients.
脑微出血患者发生颅内出血和缺血性卒中的风险增加。尚无试验专门针对脑微出血合并心房颤动患者的抗栓治疗提供指导。我们研究了抗凝治疗与不进行抗凝治疗在脑血管结局和死亡率方面的安全性。
回顾了2015年至2018年所有连续的心房颤动患者，这些患者在影像学检查时MRI显示有≥1处脑微出血。患者接受华法林、直接口服抗凝剂治疗，或未接受任何治疗。主要结局是通过国家死亡登记处获取的全因死亡率以及缺血性和出血性卒中的综合情况。所有统计检验均为双侧检验，P <.05具有统计学意义。
从患者识别到电子健康记录监测结束的中位时间间隔为9.93个月（四分位间距为2.83 - 19.17个月）。我们识别出308例患有脑微出血的心房颤动患者；128例（41.6%）接受华法林治疗，88例（28.6%）接受直接口服抗凝剂治疗，92例（29.9%）未接受任何治疗。在监测期间，发生了87例死亡、51例缺血性卒中和14例出血性卒中。三组之间复合卒中结局以及仅缺血性卒中的估计发生率无显著差异。然而，接受直接口服抗凝剂治疗的患者全因死亡率显著低于未接受抗凝治疗的患者（调整后的风险比：.44[.23,.83]，P =.012）。
在合并心房颤动和脑微出血的患者中，我们未发现华法林、直接口服抗凝剂治疗或不进行治疗在后续缺血性卒中、出血性卒中或两者方面存在差异。接受直接口服抗凝剂治疗的患者比未接受抗凝治疗的患者生存率更高。
