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1. Frequency of and factors associated with underdosing of direct oral anticoagulants in patients with ischaemic stroke and atrial fibrillation

Author

E.M. Bacas, J.C.P. Cuenca, L.L. Gata, M.M. Acevedo, A.F. García, and I.C. Naranjo

Subjects
Anticoagulantes, Dosis, Fibrilación auricular, Ictus, Riesgo, Neurology. Diseases of the nervous system, RC346-429
Abstract

Introduction: Direct oral anticoagulants (DOACs) are the first line of stroke prevention treatment in patients with non-valvular atrial fibrillation (NVAF). However, their inappropriate use is associated with increased risk of stroke, haemorrhagic complications, and mortality. The aim of this study is to analyse the factors associated with the non-prescription of anticoagulants and the underdosing of DOACs. Methods: We conducted a descriptive study of a prospective registry of patients admitted to a stroke unit due to ischaemic stroke or transient ischaemic attack (TIA) during an 1-year period. We included consecutive patients with history of NVAF with indication for anticoagulant therapy (ACT), according to the CHA2DS2-VASc scale. We analysed demographic factors, exposure to vascular risk factors, kidney function, polymedication, and short- and medium-term stroke progression. Results: Data were obtained from 60 patients admitted due to TIA or ischaemic stroke, with a previous diagnosis of NVAF, of whom 13 (21.7%) were not receiving ACT. Of the remaining 47, 25 (53.2%) were under treatment with DOACs, 21 (44.7%) with vitamin K antagonists, and 1 (2.1%) with heparin. Among patients on DOACs, 8 (32%) were receiving inappropriately low doses, with no differences between drugs.Age (80.8 vs 74.9 years, p=.05) and female sex (75% vs 35.3%, p=.05) were associated with underdosing of DOACs. Paroxysmal atrial fibrillation (46.2% vs 14.9%, p

Published
2024
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2. Frequency and Patterns of Brain Infarction in Patients With Embolic Stroke of Undetermined Source: NAVIGATE ESUS Trial

Author

Mukul Sharma, Eric E. Smith, Lesly A. Pearce, Ashkan Shoamanesh, Kanjana S. Perera, Shelagh B. Coutts, Dorte Damgaard, Sebastian F. Ameriso, Joung-Ho Rha, Boris Modrau, Byung-Woo Yoon, Marina Romano, Steven R. Messé, Jessica Barlinn, Johann Lambeck, Feryal Saad, Scott D. Berkowitz, Hardi Mundl, Stuart J. Connolly, Robert G. Hart, T.S. Field, G.J. Stotts, D.J. Gladstone, S.J. Phillips, A. Sharrief, C. Holmstedt, N. Vora, C. Wilson, B.M. Coull, A. de Havenon, L.A. Birnbaum, N. Patel, M.S. Hussain, D. Greer, S. Chen, S. Kittner, D. Mehta, T. Lowenkopf, R. Sawyer, V. Babikian, R. Zweifler, D.L. Tirschwell, C. Sila, C. Zhang, K-S. Hong, K. Oh, J.H. Heo, H-J. Bae, M.S. Park, J.S. Kim, C-S. Chung, B-C. Lee, G.P. Povedano, J.J. Martin, G.M. Bruera, L.V. Jure, J. Marti-Fabregas, I.C. Naranjo, J.M.R. Moreno, P.C. Portela, M. Gomis, J. Serena, H. Christensen, T. Christensen, S. Knecht, M. Endres, J. Berrouschot, F. Schlachetzki, S. Wunderlich, P. Kraft, P. Guyler, RC. Veltkamp, M. Burn, K. Rashed, M.J. Macleod, C. Canepa, J. Selvarajah, D. Hargroves, Y. Behnam, T.G. Robinson, L. Roveri, G. Lembo, D.S. Toni, V. Monzani, A. Cavallini, D. Popov, M. Friedrich, C. Minelli, C. Moro, R.J. Gagliardi, A. Bacellar, R. Mikulik, J. Eckstein, G. Panczel, N. Szegedi, and M.J. O’Donnell

Subjects
Brain Infarction, Male, medicine.medical_specialty, Internationality, Tobacco use, Cohort Studies, Magnetic resonance imaging, Double-Blind Method, Rivaroxaban, Internal medicine, medicine, Humans, In patient, cardiovascular diseases, Aged, Advanced and Specialized Nursing, Aspirin, medicine.diagnostic_test, business.industry, Anti-Inflammatory Agents, Non-Steroidal, Middle Aged, Magnetic Resonance Imaging, Embolic stroke, Stroke, Intracranial Embolism, Brain infarction, Cardiology, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Factor Xa Inhibitors, medicine.drug
Abstract

Background and Purpose: The spectrum of brain infarction in patients with embolic stroke of undetermined source (ESUS) has not been well characterized. Our objective was to define the frequency and pattern of brain infarcts detected by magnetic resonance imaging (MRI) among patients with recent ESUS participating in a clinical trial. Methods: In the NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source), an MRI substudy was carried out at 87 sites in 15 countries. Participants underwent an MRI using a specified protocol near randomization. Images were interpreted centrally by those unaware of clinical characteristics. Results: Among the 918 substudy cohort participants, the mean age was 67 years and 60% were men with a median (interquartile range) of 64 (26–115) days between the qualifying ischemic stroke and MRI. On MRI, 855 (93%) had recent or chronic brain infarcts that were multiple in 646 (70%) and involved multiple arterial territories in 62% (401/646). Multiple brain infarcts were present in 68% (510/755) of those without a history of stroke or transient ischemic attack before the qualifying ESUS. Prior stroke/transient ischemic attack ( P 0 ( P P =0.01) were associated with multiple infarcts. Topographically, large and/or cortical infarcts were present in 89% (757/855) of patients with infarcts, while in 11% (98/855) infarcts were exclusively small and subcortical. Among those with multiple large and/or cortical infarcts, 57% (251/437) had one or more involving a different vascular territory from the qualifying ESUS. Conclusions: Most patients with ESUS, including those without prior clinical stroke or transient ischemic attack, had multiple large and/or cortical brain infarcts detected by MRI, reflecting a substantial burden of clinical stroke and covert brain infarction. Infarcts most frequently involved multiple vascular territories. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02313909.

Published
2022
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