Venketasubramanian Narayanaswamy, Kusuma Yohanna, Yeo Leonard Leong Litt, Chan Bernard
Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore.
School of Medicine, Deakin University, Geelong, Victoria, Australia.
Cerebrovasc Dis Extra. 2025;15(1):48-55. doi: 10.1159/000543301. Epub 2024 Dec 21.
Parenteral heparin is widely used as bridging therapy while optimizing oral anticoagulation (OAC). Newer direct-acting OACs (DOACs) attain therapeutic effect very quickly. We report the use of dabigatran as bridging therapy during warfarin optimization for cardioembolic stroke in two patients who opted to receive warfarin for long-term anticoagulation for secondary stroke prevention.
Patient A was a 60-year-old man with hypertension, hyperlipidaemia, and gout who was admitted with a sudden onset of left-sided weakness. Clinically, he was alert but had right gaze preference and left-sided hemiplegia. The clinical diagnosis was of a right cortical stroke. He underwent intravenous tPA augmented with sonothrombolysis - the National Institute of Health Stroke Scale (NIHSS) score fell from 7 to 0. Repeat brain scan showed infarcts in the right frontal and parietal lobes. He was found to have atrial fibrillation (AF) and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 2 of his hospital admission. His International Normalized Ratio (INR) exceeded 2 by day 6 of anticoagulation, at which time the bridging dabigatran was stopped, fixed-dose warfarin was continued, and he was discharged well. On subsequent reviews in the clinic, his INR was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events during follow-up. Patient B was a 78-year-old man with a hypertension, hyperlipidaemia, and diabetes mellitus. He was admitted after he developed difficulty talking and mild right-sided weakness. Clinically, he was alert but had expressive aphasia and mild right-sided upper limb weakness (NIHSS 6). The clinical diagnosis was of a left cortical stroke. The brain scan showed a left posterior frontal and parietal infarct. He was out of the time window for recanalization therapy and was treated conservatively. He was found to have AF and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 1 of his hospital admission. His INR was almost 2 by day 5 of anticoagulation, at which time the bridging dabigatran was stopped and fixed-dose warfarin continued. He declined daily blood taking - his INR 4 days later was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events. He underwent rehabilitation uneventfully and was discharged well.
The use of DOACs such as dabigatran as bridging therapy during optimization of OAC is feasible. Compared to heparin as bridging therapy, DOAC has the advantage of oral administration, lower cost, and possibly lower bleeding risks. This novel practice may be applicable in thrombosis in arterial and venous circulations, e.g., ischaemic stroke, deep venous thrombosis, pulmonary embolism.
在优化口服抗凝治疗（OAC）时，肠外肝素被广泛用作桥接治疗。新型直接作用口服抗凝药（DOACs）起效非常迅速。我们报告了在两名选择接受华法林进行长期抗凝以预防继发性卒中的心源性栓塞性卒中患者中，使用达比加群作为华法林优化期间的桥接治疗。
患者A是一名60岁男性，患有高血压、高脂血症和痛风，因突发左侧肢体无力入院。临床上，他神志清醒，但有右向凝视偏好和左侧偏瘫。临床诊断为右侧皮质卒中。他接受了静脉注射组织型纤溶酶原激活剂（tPA）并辅以超声溶栓治疗——美国国立卫生研究院卒中量表（NIHSS）评分从7分降至0分。复查脑部扫描显示右侧额叶和顶叶梗死。他被发现患有心房颤动（AF），并建议进行抗凝治疗。他选择了华法林加达比加群桥接治疗，于入院第2天开始。抗凝治疗第6天时，他的国际标准化比值（INR）超过了2，此时停用桥接用的达比加群，继续使用固定剂量的华法林，随后他顺利出院。在随后的门诊复查中，他的INR处于2.0 - 3.0的治疗范围内。随访期间他没有出血或复发性缺血事件。患者B是一名78岁男性，患有高血压、高脂血症和糖尿病。他因出现言语困难和右侧轻度肢体无力入院。临床上，他神志清醒，但有表达性失语和右侧上肢轻度无力（NIHSS 6分）。临床诊断为左侧皮质卒中。脑部扫描显示左侧额后和顶叶梗死。他已超出再通治疗的时间窗，接受了保守治疗。他被发现患有AF，并建议进行抗凝治疗。他选择了华法林加达比加群桥接治疗，于入院第1天开始。抗凝治疗第5天时，他的INR接近2，此时停用桥接用的达比加群，继续使用固定剂量的华法林。他拒绝每日采血——4天后他的INR处于2.0 - 3.0的治疗范围内。他没有出血或复发性缺血事件。他顺利接受了康复治疗并出院。
在OAC优化期间使用达比加群等DOACs作为桥接治疗是可行的。与肝素作为桥接治疗相比，DOAC具有口服给药、成本较低以及可能出血风险较低的优势。这种新的做法可能适用于动脉和静脉循环中的血栓形成，如缺血性卒中、深静脉血栓形成、肺栓塞。
