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J Am Heart Assoc. 2018 Nov 20;7(22):e010133. doi: 10.1161/JAHA.118.010133.

Hemorrhagic Transformation in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Time to Initiation of Oral Anticoagulant Therapy and Outcomes.

Author information

1
1 Stroke Unit and Division of Cardiovascular Medicine University of Perugia Italy.
2
2 Department of Neurology Ospedale San Paolo Savona Italy.
3
3 Department of Neurology University of Tennessee Health Science Center Memphis TN.
4
4 Second Department of Neurology School of Medicine "Attikon" University Hospital National & Kapodistrian University of Athens Greece.
5
5 Division of Stroke and Cerebrovascular Diseases Department of Neurology The Warren Alpert Medical School of Brown University Providence RI.
6
6 Neurology Unit, Stroke Unit Arcispedale Santa Maria Nuova Azienda Unità Sanitaria Locale-IRCCS Reggio Emilia Italy.
7
7 Medical School and Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom.
8
8 SSO Stroke Unit, UO Neurologia DAI di Neuroscienze AOUI Verona Italy.
9
9 Department of Neurology Helsinki University Central Hospital Helsinki Finland.
10
10 Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy at University of Gothenburg Sweden.
11
11 Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden.
12
12 Neurologia d'urgenza e Stroke Unit Istituto Clinico Humanitas Milano Italy.
13
13 Department of Clinical and Experimental Sciences Neurology Unit University of Brescia Italy.
14
14 Internal Medicine Santa Maria Nuova Hospital Firenze Italy.
15
15 Department of Neurology Keimyung University School of Medicine Daegu South Korea.
16
16 SC Medicina e Chirurgia d'Accettazione e d'Urgenza Ospedale Lotti Pontedera Azienda USL Toscana Nordovest Pontedera Italy.
17
17 Stroke Unit AOU Senese Siena Italy.
18
18 Department of Medicine University of Thessaly Larissa Greece.
19
19 Department of Neurology Democritus University of Thrace University Hospital of Alexandroupolis Greece.
20
20 Department of Internal Medicine Ospedale Civile di Livorno Italy.
21
21 Stroke Unit Jazzolino Hospital Vibo Valentia Italy.
22
22 Department of Neurology Avezzano Hospital University of L'Aquila Avezzano Italy.
23
23 UO Gravi Cerebrolesioni San Giovanni Battista Hospital Foligno Italy.
24
24 Department of Internal Medicine Insubria University Varese Italy.
25
26 S.C. di Neurologia e S.S. di Stroke Unit ASST di Mantova Italy.
26
27 Stroke Unit Neuroscience Department University of Parma Italy.
27
28 Stroke Unit Dipartimento Geriatrico Riabilitativo University of Parma Italy.
28
29 Clinica Neurologica-Azienda Ospedaliero-Universitaria Pisa Italy.
29
30 Neurologia Ospedale Apuano Massa Carrara Italy.
30
31 Stroke Unit-Department of Neurology Santa Corona Hospital Pietra Ligure Italy.
31
25 Stroke Unit, Neurology Insubria University Varese Italy.
32
32 Abteilung für Neurologie Oberschwabenklinik gGmbH Ravensburg Germany.
33
33 Stroke Unit Ospedale di Portogruaro Italy.
34
34 Department of Neurology and Psychiatry Sapienza University of Rome Italy.
35
35 U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna Italy.
36
36 Stroke and Neurorehabilitation Unit MC 'Universal Clinic 'Oberig' Kyiv Ukraine.
37
37 Stroke Unit Metropolitan Hospital Piraeus Greece.
38
38 Second Department of Neurology AHEPA University Hospital Thessaloniki Greece.
39
39 Stroke Unit Ospedale Civico Palermo Italy.
40
40 Stroke Unit University of Debrecen Hungary.
41
41 Stroke Unit Department of Neurology Sant'Andrea Hospital La Spezia Italy.
42
42 Divisione di Neurologia Ospedale Galliera Genoa Italy.
43
43 Department of Internal Medicine Ospedale Civile di Piacenza Italy.
44
44 Municipal Budgetary Healthcare Institution of Novosibirsk City Clinical Hospital # 1 Novosibirsk State Medical University Novosibirsk Russia.
45
45 Centre Cérébrovasculaire Service de Neurologie Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois Lausanne Switzerland.
46
46 Department of Neurology Born Bunge Institute Antwerp University Hospital Antwerp Belgium.
47
47 Department of Neurology Dresden University Stroke Center Dresden Germany.
48
48 Neurology, Hamad Medical Corporation Doha Qatar.
49
49 Department of Neurology Evangelismos Hospital Athens Greece.

Abstract

Background In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation ( HT ). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT , (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT . Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3-8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0-6.0) of those without HT ; 53.1% of patients with  HT were deceased or disabled compared with 35.8% of those without HT . On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24-2.35). Conclusions In patients with HT , anticoagulation was initiated about 12 days later than patients without HT . This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability.

KEYWORDS:

atrial fibrillation; hemorrhagic transformation; stroke

PMID:
30571487
PMCID:
PMC6404429
DOI:
10.1161/JAHA.118.010133
[Indexed for MEDLINE]
Free PMC Article

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