Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study

Shadi Yaghi, Eva Mistry, Ava L. Liberman, James Giles, Syed Daniyal Asad, Angela Liu, Muhammad Nagy, Ashutosh Kaushal, Idrees Azher, Brian Mac Grory, Hiba Fakhri, Kiersten Brown Espaillat, Hemanth Pasupuleti, Heather Martin, Jose Tan, Manivannan Veerasamy, Charles Esenwa, Natalie Cheng, Khadean Moncrieffe, Iman Moeini-NaghaniMithilesh Siddu, Erica Scher, Tushar Trivedi, Aaron Lord, Karen Furie, Salah Keyrouz, Amre Nouh, Christopher R. Leon Guerrero, Adam De Havenon, Muhib Khan, Nils Henninger

Research output: Contribution to journalArticlepeer-review

4 Scopus citations

Abstract

Background and Purpose: In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage. Methods: We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations. Results: We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01-7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63-2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29-0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22-1.48]). Conclusions: Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

Original languageEnglish (US)
Pages (from-to)2724-2732
Number of pages9
JournalStroke
DOIs
StatePublished - Sep 1 2020

Keywords

  • Anticoagulant
  • atrial fibrillation
  • hemorrhage
  • heparin
  • warfarin

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

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