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Stroke. 2019 Aug;50(8):2093-2100. doi: 10.1161/STROKEAHA.118.022856. Epub 2019 Jun 21.

Anticoagulation After Stroke in Patients With Atrial Fibrillation.

Author information

1
From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.).
2
Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.).
3
Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.).
4
Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni).
5
Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy (M.Z.).
6
Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.).
7
SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari).
8
Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T.T.).
9
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden (T.T.).
10
Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).
11
Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S.M.).
12
Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani).
13
Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V.V.).
14
Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.I.S.).
15
SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Ospedale Lotti Pontedera, Azienda USL Toscana Nordovest, Pisa, Italy (G.L.).
16
Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini).
17
Department of Medicine, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.).
18
Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (K.V.).
19
Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.).
20
Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F.G.).
21
Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., A. Carolei, C.T.).
22
UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C.).
23
Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.).
24
S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone, A.L.).
25
Stroke Unit, Neuroscience Department (U.S.), University of Parma, Italy.
26
Stroke Unit, Dipartimento Geriatrico Riabilitativo (L.D.), University of Parma, Italy.
27
Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.).
28
Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.).
29
Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T.).
30
Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L.D.L., G.B.).
31
Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.).
32
Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., S.D.).
33
Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A.P.).
34
U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L.).
35
Stroke and Neurorehabilitation Unit, MC Universal Clinic 'Oberig', Kyiv, Ukraine (Y.F.).
36
Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.).
37
2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.).
38
Stroke Unit, Ospedale Civico, Palermo, Italy (S.M., M.M.B.).
39
Stroke Unit, University of Debrecen, Hungary (L.C., L.S.).
40
Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A.C., E.G., M.D.S.).
41
Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.).
42
Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.).
43
Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.).
44
Département des Neurosciences Cliniques, Centre Cérébrovasculaire, Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.).
45
Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Belgium (P.V.).
46
Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.B.).
47
Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.).
48
Department of Neurology, Evangelismos Hospital, Athens (V.G.).

Abstract

Background and Purpose- Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods- We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results- Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients (P=0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4-3.7; P<0.0001), as well as ischemic (odds ratio, 2.2; 95% CI, 1.3-3.9; P=0.005) and hemorrhagic (odds ratio, 2.4; 95% CI, 1.2-4.9; P=0.01) end points separately. Conclusions- Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.

KEYWORDS:

anticoagulants; atrial fibrillation; humans; incidence; secondary prevention

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