Premium
Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk
Author(s) -
Yaghi Shadi,
Trivedi Tushar,
Henninger Nils,
Giles James,
Liu Angela,
Nagy Muhammad,
Kaushal Ashutosh,
Azher Idrees,
Mac Grory Brian,
Fakhri Hiba,
Brown Espaillat Kiersten,
Asad Syed Daniyal,
Pasupuleti Hemanth,
Martin Heather,
Tan Jose,
Veerasamy Manivannan,
Liberman Ava L.,
Esenwa Charles,
Cheng Natalie,
Moncrieffe Khadean,
MoeiniNaghani Iman,
Siddu Mithilesh,
Scher Erica,
Leon Guerrero Christopher R.,
Khan Muhib,
Nouh Amre,
Mistry Eva,
Keyrouz Salah,
Furie Karen
Publication year - 2020
Publication title -
annals of neurology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 4.764
H-Index - 296
eISSN - 1531-8249
pISSN - 0364-5134
DOI - 10.1002/ana.25844
Subject(s) - medicine , stroke (engine) , intracerebral hemorrhage , atrial fibrillation , confidence interval , odds ratio , clinical endpoint , cohort , cardiology , embolism , pediatrics , clinical trial , subarachnoid hemorrhage , mechanical engineering , engineering
Objective Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high‐risk features on echocardiography. Methods We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0–3 days, 4–14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. Results Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0–3 days: 10.3%, 64/617; 4–14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0–3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50–4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36–1.62, p = 0.482). Interpretation In this multicenter real‐world cohort, the recommended (4–14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. ANN NEUROL 2020;88:807–816