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Management of oral anticoagulation in very old patients with non valvular atrial fibrillation related acute ischemic stroke

  • Vieri Vannucchi
  • Federico Moroni
  • Elisa Grifoni
  • Rossella Marcucci
  • Giancarlo Landini
  • Domenico Prisco
  • Luca MasottiEmail author
Article

Abstract

The optimal management of oral anticoagulation (OAC) in the acute phase of non valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) remains controversial, especially in very old patients. Therefore, the aim of our study was to evaluate the practical management of OAC in this context. We conducted an observational retrospective study on patients 85-years old and older admitted to two Italian hospitals for NVAF-related AIS. For each patient, clinical and brain computed tomography data were recorded. Type of OAC (vitamin K antagonists, VKAs or Direct Oral Anticoagulants, DOACs), dosage and starting day after AIS were registered. For each patient 90-day all cause mortality, stroke recurrence, any bleeding and modified Rankin scale (mRS) were reported. One-hundred-seventeen patients, with mean age 89.2 ± 3.4 years, were enrolled. In-hospital and 90-day mortality (out of 109 patients) were 6% and 19.7%, respectively. OAC was started in 93 patients (80.5%), on average after 6 ± 3 days from the acute event. Of them, 88 patients (94.6%) received DOACs, while 5 (5.4%) received VKAs. Patients receiving OAC were significantly younger and suffering from less severe stroke compared with patients who did not receive OAC. Patients receiving OAC presented a reduced in-hospital (2.2% vs. 20.8%, p < 0.004) and 90-day all-cause mortality (9.4% vs. 62.5%, p < 0.001). In patients receiving DOACs, low dosages were used in 87.5% of patients. The use of OAC was not associated with an increased rate of hemorrhagic transformation (HT) during hospitalization (13.2% vs. 9.5%, p = 0.54) or any bleeding at 90-day follow-up. Severe dysphagia and mRS ≥ 4 were found to be independent risk factors for not prescribing OAC. The optimal management of OAC in very old patients suffering from NVAF-related AIS remains a dilemma. In our real world study the majority of patients received OAC as secondary prevention treatment without increase in bleeding risk. Dysphagia and severe disability were independent factors for not prescribing OAC. Further investigations aimed at identifying the optimal approach to OAC during the acute phase of NVAF-related ischemic stroke in this subgroup of patients are warranted.

Keywords

Oral anticoagulation Acute ischemic stroke Atrial fibrillation Elderly 

Notes

References

  1. 1.
    Pistoia F, Sacco S, Tiseo C, Degan D, Ornello R, Carolei A (2016) The epidemiology of atrial fibrillation and stroke. Cardiol Clin 34:255–268CrossRefGoogle Scholar
  2. 2.
    Lip GY, Clementy N, Pericart L, Banerjee A, Fauchier L (2015) Stroke and major bleeding risk in elderly patients aged ≥ 75 years with atrial fibrillation: the Loire Valley atrial fibrillation project. Stroke 46:143–150CrossRefGoogle Scholar
  3. 3.
    Powers WJ, Rabinstein AA, Ackerson T et al (2018) 2018 Guidelines for the early management of patients with acute ischemic stroke. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110CrossRefGoogle Scholar
  4. 4.
    Paciaroni M, Agnelli G, Falocci N, Caso V, Becattini C, Marcheselli S et al (2015) Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: effect of anticoagulation and its timing: the RAF Study. Stroke 46:2175–2182CrossRefGoogle Scholar
  5. 5.
    Perera KS, Vanassche T, Bosch J et al (2016) Global survey of the frequency of atrial fibrillation-associated stroke: embolic stroke of undetermined source global registry. Stroke 47(9):2197–2202CrossRefGoogle Scholar
  6. 6.
    Caldeira D, Nunes-Ferreira A, Rodrigues R, Vicente E, Pinto FJ, Ferreira JJ (2019) Non-vitamin K antagonist oral anticoagulants in elderly patients with atrial fibrillation: a systematic review with meta-analysis and trial sequential analysis. Arch Gerontol Geriatr 81:209–214CrossRefGoogle Scholar
  7. 7.
    Paciaroni M, Agnelli G, Falocci N et al (2017) Early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with non-vitamin-K oral anticoagulants (RAF-NOACs) study. J Am Heart Assoc 6:e007034CrossRefGoogle Scholar
  8. 8.
    Hart RG, Pearce LA, Aguilar MI (2009) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 146:857–867CrossRefGoogle Scholar
  9. 9.
    Masotti L, Campanini M (2013) Pharmacology of new oral anticoagulants: mechanism of action, pharmacokinetics, pharmacodynamics. Ital J Med 7(Suppl 8):1–7CrossRefGoogle Scholar
  10. 10.
    Dang G, Jahangir I, Sra J, Tajik AJ, Jahangir A (2016) Atrial fibrillation and stroke in elderly patients. J Patient Cent Res Rev. 3:217–229CrossRefGoogle Scholar
  11. 11.
    Di Pasquale G, Mathieu G, Maggioni AP et al (2013) Current presentation and management of 7148 patients with atrial fibrillation in cardiology and internal medicine hospital centers: the ATA AF study. Int J Cardiol 167(6):2895–2903CrossRefGoogle Scholar
  12. 12.
    Mant J, Hobbs FD, Fletcher K et al (2007) Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized controlled trial. Lancet 370:493–503CrossRefGoogle Scholar
  13. 13.
    Rash A, Downes T, Portner R, Yeo WW, Morgan N, Channer KS (2007) A randomised controller trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing 36(2):151–156CrossRefGoogle Scholar
  14. 14.
    Kirchhof P, Ammentorp B, Darius H, De Caterina R, Le Heuzey JY, SchillingRJ Schmitt J, Zamorano JL (2014) Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on Atrial fibrillation: primary results of the prevention of thromboembolic events—European Registry in Atrial Fibrillation (PREFER in AF). Europace 16:6–14CrossRefGoogle Scholar
  15. 15.
    Chao TF, Liu CJ, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Liao JN, Chung FP, Chen TJ, Lip GYH, Chen SH (2018) Oral anticoagulation in very elderly patients with atrial fibrillation. A Nationwide Cohort Study. Circulation 138:37–47CrossRefGoogle Scholar
  16. 16.
    Ruff CT, Giugliano RP, Braunwald E et al (2014) Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383:955–962CrossRefGoogle Scholar
  17. 17.
    Ntaios G, Papavasileiou V, Diener HC, Makaritsis K, Michel P (2017) Nonvitamin-K-antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and previous stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized controlled trials. Int J Stroke 12:589–596CrossRefGoogle Scholar
  18. 18.
    Voukalis C, Lip GYH (2017) Oral anticoagulation for elderly patients with non-valvular atrial fibrillation: recent insights from randomised trials and the ‘real world’. Heart 103:977–978CrossRefGoogle Scholar
  19. 19.
    Abdul-Rahim AH, Fulton RL, Frank B et al (2015) Association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from VISTA. Eur J Neurol 22:1048–1055CrossRefGoogle Scholar
  20. 20.
    Masotti L, Grifoni E, Dei A et al (2019) Direct oral anticoagulants in the early phase of non valvular atrial fibrillation-related acute ischemic stroke: focus on real life studies. J Thromb Thrombolysis 47:292–300CrossRefGoogle Scholar
  21. 21.
    Moroni F, Masotti L, Vannucchi V et al (2018) Confidence in the use of direct oral anticoagulants in the acute phase of nonvalvular atrial fibrillation-related ischemic stroke over the years: a real-world single-center study. J Stroke Cerebrovasc Dis 27(1):76–82CrossRefGoogle Scholar
  22. 22.
    Canavero I, Micieli G, Paciaroni M (2018) Decision algorithms for direct oral anticoagulant use in patients with nonvalvular atrial fibrillation: a practical guide for neurologists. Clin Appl Thromb Hemost 24:396–404CrossRefGoogle Scholar
  23. 23.
    Umei M, Kishi M, Sato T, Shindo A, Toyoda M, Yokoyama M, Matsushita M, Ohnishi S, Yamasaki M (2017) Indications for suboptimal low-dose direct oral anticoagulants for non-valvular atrial fibrillation patients. J Arrhythm 33:475–482CrossRefGoogle Scholar
  24. 24.
    Barra ME, Fanikos J, Connors JM, Sylvester KW, Piazza G, Goldhaber SZ (2016) Evaluation of dose-reduced direct oral anticoagulant therapy. Am J Med 129:1198–1204CrossRefGoogle Scholar
  25. 25.
    Brook R, Aswapanyawongse O, Tacey M, Kitipornchai T, Ho P, Lim HY (2019) Real-world direct oral anticoagulants experience in atrial fibrillation: falls risk and low dose anticoagulation are predictive of both bleeding and stroke risk. Intern Med J.  https://doi.org/10.1111/imj.14640 CrossRefPubMedGoogle Scholar
  26. 26.
    Alnsasra H, Haim M, Senderey AB et al (2019) Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: experience from the real world. Heart Rhythm 16:31–37CrossRefGoogle Scholar
  27. 27.
    Deguchi I, Tanahashi N, Takao M (2018) Selection of oral anticoagulants in ischemic stroke patients with nonvalvular atrial fibrillation. J Stroke Cerebrovasc Dis 27:2627–2631CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Internal MedicineSanta Maria Nuova HospitalFlorenceItaly
  2. 2.Internal Medicine IISan Giuseppe HospitalEmpoliItaly
  3. 3.Department of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly

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