Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA.
Department of Neurology, Montefiore Medical Center, New York, NY, USA.
J Stroke Cerebrovasc Dis. 2020 Jul;29(7):104888. doi: 10.1016/j.jstrokecerebrovasdis.2020.104888. Epub 2020 May 13.
Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF.
The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status.
Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10-2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06-3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke.
Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.
了解接受抗凝治疗的患者发生缺血性卒中的相关因素是改善房颤（AF）患者卒中预防策略的重要目标。本研究旨在确定 AF 患者发生缺血性卒中时与治疗或超治疗抗凝状态相关的因素。
启动抗凝治疗后心源性脑卒（IAC）研究是一项多中心研究，汇集了美国 8 个综合卒中中心卒中登记处的数据。连续纳入在 AF 背景下因急性缺血性卒中住院的患者。本研究仅纳入报告在缺血性卒中时服用华法林的患者。未接受抗凝治疗的患者和报告使用直接口服抗凝剂的患者被排除在外。分析基于治疗性（INR≥2）与亚治疗性（INR＜2）抗凝状态进行分层。我们使用二元逻辑回归模型，通过调整相关混杂因素，确定与抗凝状态独立相关的因素。特别是，我们试图确定供应梗死动脉的 50%或更多管腔狭窄（提示存在竞争的动脉粥样硬化机制的标志物）和小卒中灶（≤10ml；提示存在竞争的小血管疾病机制）与抗凝状态的关系。
在 IAC 研究中，共纳入 2084 例患者，其中 382 例符合纳入标准。平均年龄为 77.4±10.9 岁，52.4%（200/382）为女性。共有 222 例（58.1%）患者的 INR 处于亚治疗范围。在调整后的模型中，小卒中灶（OR 1.74，95%CI 1.10-2.76，p=0.019）和供应梗死动脉的 50%或更多狭窄的动脉粥样硬化（OR 1.96，95%CI 1.06-3.63，p=0.031）与指数卒中时 INR≥2 独立相关。
小卒中灶（≤10ml）和同侧狭窄程度达到 50%或以上的动脉粥样硬化可能提示存在竞争的卒中机制。通过针对其他缺血性卒中机制来改善患者结局，可能为 AF 患者改善卒中预防策略提供重要机会。
