Liu Yigang, Jiang Dudu, Jin Lingjing, Nie Zhiyu
Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China.
Department of Neurology, Seventh People's Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China.
Ann Palliat Med. 2020 Sep;9(5):2448-2454. doi: 10.21037/apm-19-366. Epub 2020 Aug 18.
Cardiogenic cerebral embolism is one of the most common causes of ischemic stroke. In general, cardioembolic stroke is associated with more severe neurological deficits and higher early mortality, as well as a worse functional outcome. Oral anticoagulant (OAC) therapy could reduce the risk of stroke significantly. However, several limitations have led to it being underused, which raises the failure of anticoagulant therapy. This study aimed to investigate the patients with atrial fibrillation presented cardioembolic stroke who underwent OAC therapy, and to assess treatment efficacy, and outcomes, especially the international normalized ratio (INR) value in the acute phase.
Clinical data of 306 patients with cardioembolic stroke and etiology of atrial fibrillation were retrospectively analyzed, and demographics, cardiovascular risk factors, embolic cardiopathy, CHADS2 and CHA2DS2-VASc score, HAS-BLED score, INR value, TOAST subtypes, OCSP classification, modified Rankin Scale (mRS) scores and prognosis were evaluated.
The median score on the CHADS2 and CHA2DS2-VASc scales was 3 and 4, respectively; The median score on the HAS-BLED scale was 2. Only 33 patients (10.8%) were in therapeutic INR range at the onset of stroke. In the acute phase, 233 patients (76.1%) continued to use OAC therapy, and 73 patients were suspended. Eighteen patients (24.7%) resumed treatment after an average of 32 days. Thirty-nine of 251 survivors with nonvalvular atrial fibrillation were modified to novel oral anticoagulants (NOACs). At 3 months follow-up, patients with INR ≥1.7 had significantly better prognosis than those with INR <1.7, both in the percentage of patients with functional independence (78.9% vs. 41.2%) and in mortality (7.0% vs. 25.0%) (P<0.001).
Patients presented cardioembolic stroke despite being treated with OAC, especially those with a subtherapeutic INR value, raises the failure of anticoagulant therapy. Despite the ineffectiveness of the OAC, the prognosis is better when the INR ≥1.7 at the initiation of the stroke.
心源性脑栓塞是缺血性卒中最常见的病因之一。一般来说，心源性栓塞性卒中与更严重的神经功能缺损、更高的早期死亡率以及更差的功能预后相关。口服抗凝剂（OAC）治疗可显著降低卒中风险。然而，一些局限性导致其使用不足，这增加了抗凝治疗的失败率。本研究旨在调查接受OAC治疗的房颤相关性心源性栓塞性卒中患者，评估治疗效果和结局，尤其是急性期的国际标准化比值（INR）值。
回顾性分析306例心源性栓塞性卒中且病因是房颤患者的临床资料，评估人口统计学、心血管危险因素、栓塞性心脏病、CHADS2和CHA2DS2-VASc评分、HAS-BLED评分、INR值、TOAST亚型、OCSP分类、改良Rankin量表（mRS）评分及预后。
CHADS2和CHA2DS2-VASc量表的中位数评分分别为3分和4分；HAS-BLED量表的中位数评分为2分。仅33例患者（10.8%）在卒中发作时INR处于治疗范围。急性期，233例患者（76.1%）继续使用OAC治疗，73例患者暂停使用。18例患者（24.7%）平均在32天后恢复治疗。251例非瓣膜性房颤幸存者中有39例改用新型口服抗凝剂（NOACs）。在3个月随访时，INR≥1.7的患者在功能独立患者百分比（78.9%对41.2%）和死亡率（7.0%对25.0%）方面的预后均显著优于INR<1.7的患者（P<0.001）。
尽管接受了OAC治疗，但仍发生心源性栓塞性卒中的患者，尤其是INR值低于治疗范围的患者，提示抗凝治疗失败。尽管OAC治疗无效，但卒中发作时INR≥1.7时预后较好。
