Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.).
Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.).
Stroke. 2020 Aug;51(8):2347-2354. doi: 10.1161/STROKEAHA.120.030143. Epub 2020 Jul 10.
The optimal timing for starting oral anticoagulant after an ischemic stroke related to atrial fibrillation remains a challenge, mainly in patients treated with systemic thrombolysis or mechanical thrombectomy. We aimed at assessing the incidence of early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with thrombolytic therapy and/or thrombectomy, who then received oral anticoagulants for secondary prevention.
We combined the dataset of the RAF and the RAF-NOACs (Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non-Vitamin K Oral Anticoagulants) studies, which were prospective observational studies carried out from January 2012 to March 2014 and April 2014 to June 2016, respectively. We included consecutive patients with acute ischemic stroke and atrial fibrillation treated with either vitamin K antagonists or nonvitamin K oral anticoagulants. Primary outcome was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding within 90 days from the inclusion. Treated-patients were propensity matched to untreated-patients in a 1:1 ratio after stratification by baseline clinical features.
A total of 2159 patients were included, 564 (26%) patients received acute reperfusion therapies. After the index event, 505 (90%) patients treated with acute reperfusion therapies and 1287 of 1595 (81%) patients untreated started oral anticoagulation. Timing of starting oral anticoagulant was similar in reperfusion-treated and untreated patients (median 7.5 versus 7.0 days, respectively). At 90 days, the primary study outcome occurred in 37 (7%) patients treated with reperfusion and in 146 (9%) untreated patients (odds ratio, 0.74 [95% CI, 0.50-1.07]). After propensity score matching, risk of primary outcome was comparable between the 2 groups (odds ratio, 1.06 [95% CI, 0.53-2.02]).
Acute reperfusion treatment did not influence the risk of early recurrence and major bleeding in patients with atrial fibrillation-related acute ischemic stroke, who started on oral anticoagulant.
对于与心房颤动相关的缺血性卒中患者，开始口服抗凝治疗的最佳时机仍然是一个挑战，主要是在接受全身溶栓或机械取栓治疗的患者中。我们旨在评估接受溶栓治疗和/或取栓治疗的急性缺血性卒中和心房颤动患者，随后接受口服抗凝药物二级预防时的早期复发和大出血发生率。
我们将 RAF 和 RAF-NOACs（非维生素 K 口服抗凝剂治疗急性缺血性卒中和心房颤动患者的早期复发和大出血）研究的数据合并，这两项研究分别于 2012 年 1 月至 2014 年 3 月和 2014 年 4 月至 2016 年 6 月进行，为前瞻性观察性研究。我们纳入了接受维生素 K 拮抗剂或非维生素 K 口服抗凝剂治疗的急性缺血性卒中和心房颤动的连续患者。主要结局是从纳入之日起 90 天内发生的卒中、短暂性脑缺血发作、症状性系统性栓塞、症状性脑出血和主要的脑外出血的复合事件。在按基线临床特征分层后，采用 1:1 比例对治疗患者和未治疗患者进行倾向评分匹配。
共纳入 2159 例患者，564 例（26%）患者接受了急性再灌注治疗。在指数事件后，505 例（90%）接受急性再灌注治疗的患者和 1595 例（81%）未治疗的患者开始接受口服抗凝治疗。再灌注治疗和未治疗患者开始口服抗凝的时间相似（中位数分别为 7.5 天和 7.0 天）。90 天时，再灌注治疗的 37 例（7%）患者和未治疗的 146 例（9%）患者发生主要研究结局（比值比，0.74[95%CI，0.50-1.07]）。经倾向评分匹配后，两组的主要结局风险相当（比值比，1.06[95%CI，0.53-2.02]）。
对于开始口服抗凝的心房颤动相关急性缺血性卒中患者，急性再灌注治疗并未增加早期复发和大出血的风险。
