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Introduction: Atrial fibrillation (AF) is associated with increased risk of stroke and thromboembolism. Patients with AF have a higher incidence of renal impairment, which may influence the risks of systemic thromboembolism or bleeding. We determined how different oral anticoagulants affect plasma clot properties and whether progressive renal dysfunction affects plasma clot properties in patients on warfarin., Materials and Methods: We studied 257 patients with AF receiving oral anticoagulants. Furthermore, we recruited 192 separate patients with AF on warfarin and divided them in 4 groups based on estimated glomerular filtration rate (eGFR). Platelet poor plasma was prepared and clot formation and fibrinolysis was monitored kinetically up to 1 h., Results: Rate of clot formation was significantly slower with dabigatran and rivaroxaban. Time between 50% clotting and 50% lysis was prolonged in patients receiving warfarin compared to NOACs. Time to 50% lysis from maximum absorbance was significantly shorter in patients receiving rivaroxaban. Time between 50% clotting and 50% lysis became significantly prolonged with worsening eGFR. Time to 50% lysis from maximum absorbance was prolonged as renal function worsened., Conclusions: Compared to warfarin, NOACs differently modulate coagulation and fibrinolysis under ex vivo conditions. Worsening renal function in AF patients on warfarin prolongs fibrinolysis, potentially increasing the risk of thrombosis., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: No pooled analysis has been undertaken to assess the efficacy and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin in the subgroup of patients with atrial fibrillation (AF) and heart failure (HF), including edoxaban data from recent randomized controlled trials (RCTs)., Methods: Comprehensive literature searches were conducted using the Cochrane Library, MEDLINE, and Scopus databases from inception to April 2015. Statistical analyses were performed using RevMan 5.3 software., Results: Four RCTs were included: 19 122 of 32 512 AF patients with HF were allocated to a NOAC (13 384 receiving single-/high-dose NOAC regimens), and 13 390 to warfarin. Among AF patients with HF, single/high-dose NOACs significantly reduced the risk of stroke/systemic embolic (SE) events by 14% [odds ratio0.86, 95% confidence interval (CI) 0.76-0.98), and had a 24% lower risk of major bleeding(OR 0.76, 95% CI 0.67-0.86). For low-dose NOAC regimens, comparable efficacy to warfarin for stroke or SE events (OR 1.02, 95% CI 0.86-1.21) and a non-significant trend for lower major bleeding was observed. Regardless of high- or low-dose NOAC, the incidences of both major bleeding and stroke/SE in AF patients with HF were similar to those without HF. Atrial fibrillation patients with HF on NOACs had a 41% lower risk of intracranial haemorrhage compared with those without HF (OR 0.59, 95% CI 0.40-0.87)., Conclusion: Among AF patients with HF, single-/high-dose NOAC regimens have a better efficacy and safety profile, but low-dose regimens had similar efficacy and safety to warfarin. NOACs were similarly effective or even safer (less intracranial haemorrhage) in AF patients with HF compared with those without HF., (© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.)

Oral anticoagulation therapy is the mainstay of stroke prevention in nonvalvular atrial fibrillation patients. Vitamin K antagonists (such as warfarin) have been effective conventional oral anticoagulants for several decades. However, due to their limitations in clinical use, several nonvitamin K antagonist oral anticoagulants (NOACs, including dabigatran, rivaroxaban, apixaban and edoxaban) have been developed. Nonetheless, no head to head trials have been performed to directly compare these NOACs in patient cohorts. In this review article, two direct factor Xa inhibitors, apixaban and edoxaban, are briefly described with focus on their pharmacokinetic and pharmacodynamic profiles, plus drug interactions. Moreover, both efficacy and safety will be discussed based on the available data from the large Phase III clinical trials and indirect comparison studies.

Introduction: Atrial fibrillation (AF) is the most common arrhythmia and brings about significant mortality and morbidity as a result of heart failure and ischemic stroke. Besides vitamin K antagonists (VKA), several new pharmacological agents (nonvitamin K antagonist oral anticoagulants [NOACs]) and procedures have since been developed to improve stroke prevention efforts in AF., Areas Covered: This paper will discuss the antiplatelet agents, VKA and NOACs, and their efficacy and safety for stroke prevention in AF. Focus will be placed on the NOACs, their limitations and special considerations. A short assessment of other nonpharmacological antithrombotic procedures will also be made. An extensive PubMed search was used to identify suitable papers., Expert Opinion: Despite the advent of NOACs, the VKAs will remain as an important oral anticoagulant due to its versatility. However, convenience and limited food or drug interactions will make NOACs attractive options. The choice between various NOACs will depend on several important factors as illustrated below. Over time, the role for antiplatelet agents will gradually diminish. Left atrial appendage occlusion devices have shown promising results and may have the potential to change the way clinicians manage thromboembolism risks related to AF.

Purpose of Review: Oral anticoagulation (OAC) remains the mainstay for prevention of ischaemic stroke in atrial fibrillation. This article reviews the latest evidence and development of new oral anticoagulants for the prevention of ischaemic stroke, as well as bleeding risk assessment, mitigation and management., Recent Findings: Decision-making for stroke prevention has evolved towards the initial identification of 'low-risk' patients who do not need any antithrombotic therapy. Subsequent to this step, patients with at least 1 stroke risk factor can be offered effective stroke prevention, which is OAC. There is increased morbidity and mortality amongst warfarin users, if time in therapeutic range is poor. New oral anticoagulants (such as dabigatran, rivaroxaban, apixaban and edoxaban) offer relative efficacy, safety and convenience compared to warfarin, in relation to stroke prevention in atrial fibrillation. Bleeding risk can be assessed by HAS-BLED score, whereas the new SAMe-TT2R2 score can predict the patient's suitability for vitamin K antagonists., Summary: The landscape for stroke prevention in atrial fibrillation has greatly changed. It is no longer a question of 'if we treat' but more of 'how to treat', as the presence of one or more stroke risk factors in atrial fibrillation confers a risk of fatal and devastating strokes. OAC use, whether as well controlled vitamin K antagonists or nonvitamin K antagonists oral anticoagulant, will reduce the burden of stroke in atrial fibrillation.

Background: Knowing the types and frequency of medical complications of stroke patients during inpatient rehabilitation, together with the ability to identify high-risk patients, would be extremely helpful for providing the best possible physiologic environment for their recovery., Methods: A retrospective study was conducted. Charts of 346 stroke patients who were consecutively admitted or transferred for inpatient rehabilitation in a tertiary care hospital from October 1997 to September 1998 were reviewed. Demographic and stroke characteristics, preexisting neuromedical conditions, neurological deficits, disability level, medical complications occurring during inpatient rehabilitation, and complications that required transfer off the rehabilitation ward were recorded for each patient. Univariate and stepwise multiple logistic regression analyses were performed to determine the factors that were significantly associated with the occurrence of any medical complication., Results: Forty-four percent of patients experienced 1 or more complications. The most common complications were musculoskeletal pain (15.0%), urinary tract infection (13.6%), depression (9.3%), upper gastrointestinal tract bleeding (4.9%), and pneumonia (4.9%). Ten patients were transferred to the acute care ward during admission because of severe medical complications. Among them, 5 had a recurrent stroke, 3 had pneumonia, 1 had ventriculoperitoneal shunt obstruction, and 1 had organic psychosis. The occurrence of any of the medical complications was significantly associated with the following factors which were presented at admission or transfer to the rehabilitation ward: being female, having no voluntary movement of the affected hand, being more functionally dependent, and having to undergo Foley catheter insertion., Conclusions: Medical complications were common among stroke patients undergoing inpatient rehabilitation. Prevention and proper management are also very important in the rehabilitation ward.

Objective: To investigate the feasibility of using a foot contact pattern to predict neurologic recovery and the effect of ambulation training in hemiplegic stroke patients., Design: Case-comparison study., Setting: Gait laboratory in a tertiary care center., Participants: Sixty-five functionally ambulant hemiplegic stroke patients, and 30 healthy subjects serving as the control group., Interventions: Gait analyses were performed by using the conventional gait analysis system (6 cameras) and the portable Computer DynoGraphy (CDG) system. Main outcome measures Walking velocity, step length, and cadence were measured from the conventional gait analysis system. Cyclogram, gaitline, and ground reaction force (GRF) patterns were recorded with the CDG system., Results: Velocity, cadence, and step length increased in higher Brunnstrom stages (P<.01). Negative correlation was noted between the Brunnstrom stages and the foot contact patterns (P<.01). Lower cyclogram, GRF, and gaitline patterns were expected in subjects with higher Brunnstrom stages. There were high prediction probabilities between cyclogram, gaitline, and GRF patterns., Conclusions: Foot contact pattern can be a simple and reliable indicator of hemiplegic gait in stroke patients. It is closely related to patient's neurologic status and is correlated with parameters obtained from conventional gait analysis systems. Pathologic presentations are noted in both the affected and unaffected limbs, suggesting that rehabilitation programs should be implemented on both sides.