Can stroke patients with atrial fibrillation be anticoagulated?

*Only for medical professionals to read and refer to 2 cases, 3 aspects, wonderful content! Anticoagulant therapy for ischemic stroke patients with atrial fibrillation has always been the focus of discussion in the medical community at home and abroad
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At the 7th Annual Conference of the Chinese Stroke Society (CSA&TISC 2021), Professor Liu Yanfang from the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, reviewed the contents of the domestic and foreign guidelines on stroke anticoagulation treatment in recent years
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The inventory is divided into two parts, typical cases and discussion of key issues
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Professor Liu started with the situation of two typical patients, and then proceeded with research and sharing of relevant guidelines from three aspects: treatment plan, treatment start time, and refinement to drug selection
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Figure 1: Three key issues shared this time (Professor Tu Yuan ppt) 01 Typical Case Sharing Patient 1: An 81-year-old male patient, the main complaint is instability of walking, weakness of the left lower limb for two days, previous atrial fibrillation, chronic obstructive History of lung disease (COPD), hypertension, coronary heart disease
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On physical examination, the blood pressure was 159/97mmHg, the heart rate was 84 beats/min, and the rhythm was irregular.
The National Institutes of Health Stroke Scale (NIHSS) scored 3 points
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Imaging examination MRI showed that the patient had new infarcts in the cerebellum and frontal parietal lobe, and white matter lesions; SWI showed micro hemorrhage in the left thalamus
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CTA of the left atrial pulmonary vein was performed, and multiple thrombosis in the left atrial appendage was seen
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Patient 2: An 85-year-old female patient complained of speech disability with left limb weakness for two hours, a three-year history of atrial fibrillation, and regularly taking 110 mg bid of dabigatran
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Nine days before the onset, due to gastrointestinal bleeding, anticoagulant drugs were discontinued, and a total of 1600 ml of blood transfusion was given for 3 days, and the NIHSS score was 10 points
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Imaging examination showed a new infarct in the right middle cerebral artery distribution area
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02 Discussion of key issues ■ Question 1: What is the option for secondary prevention of patients with stroke and atrial fibrillation? In 2021, the American Heart Association (AHA) issued guidelines for the prevention of stroke in patients with acute ischemic stroke/transient ischemic attack (TIA)
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The guidelines point out that if there are no contraindications, almost all patients are recommended for antithrombotic therapy, including antiplatelet and anticoagulation therapy
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Atrial fibrillation is still a high-risk factor for recurrence of ischemic stroke.
Therefore, if there are no contraindications, anticoagulation therapy should still be actively carried out.
Can patients with stroke complicated with atrial fibrillation choose antiplatelet instead of anticoagulation? In fact, this is not a new question, as early as 30 years ago, EAFT research has tried to answer
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The EAFT study is a multi-center, randomized, placebo-controlled study
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Enrolled 1,007 patients with non-valvular atrial fibrillation combined with TIA/light stroke.
Among them, 669 patients suitable for anticoagulation were randomized to receive anticoagulation, aspirin or placebo treatment.
The average follow-up time was 2.
3 years.
The primary endpoint was death caused by vascular disease.
, Non-fatal stroke, non-fatal myocardial infarction or systemic embolism
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The results showed that among the subjects, the event-free survival rate of the anticoagulant treatment group was the highest
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Figure 2: Results of the EAFT study (Professor Tu Yuan ppt) In 2014, there was another prospective observational trial, which included 2161 patients with acute ischemic stroke and atrial fibrillation, and 8.
0% did not receive antithrombotic treatment at the time of discharge.
21.
6% received only antiplatelet therapy, 39.
3% received oral anticoagulation therapy alone, and 31.
1% received anticoagulation + antiplatelet therapy.
The main composite endpoints were death, recurrence of ischemic stroke and admission, and myocardial infarction/hemorrhage
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The results showed that the primary endpoint risk increased by 51% in the non-antithrombotic treatment group, and the primary endpoint risk increased by 31% in the antiplatelet therapy group alone.
Anticoagulation combined with antiplatelet therapy has a trend to reduce the risk of the primary endpoint event
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Therefore, compared with antiplatelet therapy, patients with ischemic stroke and atrial fibrillation receiving anticoagulation therapy may benefit significantly
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Not only the results of this study, but also a number of follow-up guidelines at home and abroad have stated that antiplatelet therapy is not recommended or recommended, and anticoagulation therapy is recommended for secondary prevention
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Figure 3: Chinese and foreign guidelines recommend antiplatelet therapy in the secondary prevention of patients with atrial fibrillation stroke (Professor Tu Yuan ppt) ■ Question 2: When should anticoagulation therapy be initiated? Based on the selection of the secondary prevention program, when should treatment be initiated? Professor Liu pointed out that the problem of uncertainty about the start time of treatment is actually very common.
An online survey of 121 stroke doctors in the UK in 18 showed that 95% of doctors were not sure about the start time of anticoagulation
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When clinical treatment is confused, it is necessary to seek answers from the academic community.
The RAF study published on Stroke in 2015 tried to answer this question
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A prospective multi-center cohort study between 2013 and 2014 included 1029 consecutive patients with acute ischemic stroke and atrial fibrillation in 29 centers, and observed the effects of different antithrombotic therapy initiation times on the primary endpoint (similar to the previous study).
Similar)
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The results show that the risk of the primary endpoint event is the lowest 4-14 days after the stroke event, which proves that the appropriate time to initiate anticoagulation therapy is 4-14 days after the onset of the stroke
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Figure 4: The results of the RAF study (Professor Tu Yuan ppt) The reason why many doctors are uncertain about the timing of anticoagulation is that doctors are concerned about the risk of hemorrhagic stroke after taking the drug.
The 2017 RAF-NOAC study can be very Good to alleviate everyone's concerns
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This is a prospective observational study that included 1127 patients with acute ischemic stroke combined with atrial fibrillation.
33.
8% of the patients received dabigatran treatment, 32.
5% of the patients received rivaroxaban treatment, 33.
7 % Received apixaban treatment
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Researchers evaluated the relationship between the incidence of ischemic and hemorrhagic time and the time to start oral anticoagulants (NOAC)
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Studies have found that using NOAC within 3-14 days after the occurrence of an acute ischemic stroke, the risk of ischemic and hemorrhagic events is relatively lower
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At the 2020 International Stroke Conference (ISC), a prospective observational study involving 2550 patients from Europe and Japan showed that starting NOAC treatment within five days after stroke does not increase the risk of intracranial hemorrhage
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Figure 5: Results of the RAF-NOAC study (Professor Tu Yuan ppt) In terms of guidelines, Professor Liu used a time axis to summarize and compare the recommendations of different international guidelines on the timing of anticoagulation from 2016 to 2021
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For example, the 2016 ESC recommendation is based on the NIHSS scores of patients after acute ischemic stroke; the 2019 ESO guidelines recommend that patients be determined based on the infarct size of a new stroke; the 2021 AHA guidelines recommend that stroke patients should be considered for the risk of hemorrhagic transformation first The judgment
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Figure 6: From 2016 to 2021, the domestic and foreign guidelines recommend the start time of anticoagulation therapy (Professor Tu Yuan ppt) and the restart of anticoagulation therapy for patients with intracranial hemorrhage atrial fibrillation, the decision-making process recommended by the 2020 ESC guidelines It is to first consider the possibility of hemorrhagic stroke recurrence, and then correct the changeable bleeding risk factors.
Finally, the cardiology department should discuss with neurologists to assess the risks and benefits of restarting anticoagulation therapy before making a decision
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■ Question 3: How to choose anticoagulant drugs? After deciding when to start anticoagulation therapy, what drugs to use is the last question.
Professor Liu said that the current domestic and foreign guidelines are relatively consistent and recommend new oral anticoagulants (NOAC) with high levels of evidence
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Figure 7: Recommendations for anticoagulant drugs in domestic and foreign guidelines from 2018 to 2021 (Professor Tu Yuan ppt) For specific drug selection, Professor Liu provided us with a detailed comparison table showing the use of NOAC in the prevention of atrial fibrillation stroke The results of randomized controlled trials included the risk of primary clinical endpoints such as stroke, cardiovascular death, and intracranial hemorrhage in comparison with warfarin in different doses and types of NOAC
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Figure 8: Prevention endpoint events and bleeding risk of different brands/different doses of anticoagulants compared with warfarin (Professor Tu Yuan ppt) 03 Return cases and future prospects After answering three questions, Professor Liu returned to the original two On each case
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According to the CHADS2-VAS score, HAS-BLED score, advanced age, number of microbleeds, infarct size, and presence of atrial thrombus, Professor Liu and his team initiated anticoagulation therapy for the first patient three days after the onset of disease.
Rivaroxaban 15mg qd regimen; the second patient started anticoagulation therapy 14 days after the onset of onset, and chose rivaroxaban 10mg qd regimen
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Figure 9: Case evaluation results (Professor Tu Yuan ppt) Finally, Professor Liu pointed out that the treatment of patients with atrial fibrillation should have a multidisciplinary team working together, and achieving patient-centered comprehensive management is the direction of everyone's future efforts
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Source of this article: Medical Neurology Channel.
This article is organized: Zhong Chuwen.
This article is reviewed by Professor Liu Yanfang.
Editor in charge of Beijing Tiantan Hospital, Capital Medical University.
Editor: Mr.
Lu Li.
Copyright statement.
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