[ad_1]
In a retrospective study – published online in the "Journal of Stroke & Cerebrovascular Diseases" – it was badyzed how oral anticoagulants (OACs) were selected for patients with acute ischemic stroke with non-valvular atrial fibrillation (FANV ). This choice was influenced by the use of warfarin at the time of admission, clinical severity at discharge from the hospital and renal function.
In a retrospective study – published online in the "Journal of Stroke & Cerebrovascular Diseases" – it was badyzed how oral anticoagulants (OACs) were selected for patients with acute ischemic stroke with non-valvular atrial fibrillation (FANV ). It was found that this choice was influenced by the use of warfarin at admission, clinical severity at discharge from hospital, and renal function.
"Stroke patients with FANV are an absolute indication for secondary prevention. "Ischemic Stroke with Anticoagulant Therapy" reminiscent of the authors, led by Igiro Deguchi of the Department of Neurology of the International Medical Center of the Medical University of Saitama, Hidaka, Japan.
"ACOs used in Japan include warfarin and direct acting OAC (DOAC). However, there are no definitive guidelines for the choice of warfarin or a DOAC to prevent recurrent stroke in patients with FANV, and both types of medications are used at the discretion of physicians depending on the clinical condition of each patient.
However, an observational study (The Stroke Study on the Assessment and Improvement of Urgent Risk Factors [SAMURAI] -NVAF) revealed that patients with poorer clinical outcomes at discharge from the hospital were more likely to be already treated warfarin, although the study was conducted since 2011 (when the first DOAC, dabigatran was approved) in March 2014.
In this study, Deguchi and colleagues examined the choice of AC for the treatment of cerebral infarction with FANV in patients treated since September 2014, when the four AODs (dabigatran, rivaroxaban, apixaban, edoxaban) were available in Japan
Data from the Retrospective Observational Study
This study included: 297 patients affected by a stroke with FANV admitted to the Hidaka Hospital between September 2014 and december 2017 and which were subsequently transferred to three institutions or rejected. Baseline clinical characteristics were compared between patients who received warfarin and those prescribed DOAC. A total of 280 out of 297 patients (94.3%) received oral anticoagulant therapy, of which 36 were warfarin and 244 received DOAC.
Age, percentage of patients with heart failure, CHADS2 score before the onset of stroke, proportion of subjects receiving warfarin at admission, percentage of patients with nasogastric tube at the exit of the hospital, and the modified Rankin Scale score (mRS) at discharge from the hospital was significantly higher in the warfarin group than in the DOAC group, while the clearance of the creatinine was significantly higher in the DOAC group.
Multiple logistic regression, intake of warfarin at admission and the number of SRM at discharge from the hospital were badociated with the selection of warfarin, while the clearance of the creatinine was badociated with selection by DOAC
Logic Decision Making
In the present study, the authors reiterate that DOACs were selected in 94% of patients receiving ACO. In addition, adherence to warfarin treatment at admission, severity at discharge from hospital and the value of creatinine clearance (CCr, Cockcroft-Gault equation) were important factors influencing the choice of AC (warfarin or DOAC).
"In the SAMURAI-NVAF study, warfarin was selected in 58% of patients receiving ACO. Interestingly, this difference was influenced by the period during which follow-up was done. In fact, dabigatran was the only DOAC available at the start of the follow-up period and no fine-grained form of DOAC was approved, "note the researchers.
"Therefore, it may have been difficult then to use a DOAC in individuals with an acute nasogastric tube.In contrast, the DOAC prescription was simpler during our period of study since 4 types of DOACs were available, including a granular form, "they explain
" Our findings on the relationship between clinical severity and choice of OAC are consistent with previous studies, "the researchers write. for example, the outgoing MRS scores were significantly higher in warfarin treated subjects than in those treated with DOAC, while warfarin was prescribed in severe cases. "
In particular, the SAMURAI study -NVAF it was shown that warfarin was prescribed in 91.1% of patients in intensive care with an MRS score of 5.
"In long-term care units, it is difficult to continue treatment with DOAC,which are more expensive than warfarin, "note the authors. "Indeed, among the patients in this study requiring transfer to other institutions, the percentage of those transferred to long-term care units was only 2.0% in the DOAC group. against 30.6% in the warfarin group ".
"Therefore" they continue "treating physicians can select warfarin in consideration of possible future transfer to long-term care units, based on age of patients, clinical severity and other clinical characteristics ". The present study differs from that of the SAMURAI-NVAF study, in which 74.7% of patients with ischemic stroke with an mRS score of 5 received a DOAC, while we prescribed DOAC to many patients even with those with severe neurological sequelae, specify Deguchi and colleagues
"Our results also showed that warfarin was more likely to be selected in patients who took it as early as the stroke. probably due to the fact that the appropriate initial dose of warfarin can be estimated with INR at the time of admission, making the use of warfarin easier than the new ACOs, "specify
"On the contrary, DOAC are selected in patients with good renal function," note the authors. "Because DOAC blood levels are determined by their renal excretion rate, doses of DOAC are determined according to each patient's kidney function." Therefore, DOACs are easier to use in patients with better renal function, which may explain the higher rate of DOAC selection in these patients.
Of the non-prescription ACO patients, 0.6% (12 patients) were over 80 years old and everyone had serious consequences after leaving the hospital. In addition, 3 of these patients had end-stage cancer with a life expectancy of less than 6 months
. "For elderly patients with unresolved severe sequelae or concomitant diseases such as malignancies, it is not possible to There is no definitive answer about the possibility of performing stroke prophylaxis with OAC, baduming the risk of treatment-related complications or not performing treatment as well as the risk of patient death due to a Stroke: It depends on the attitude of the individual doctor to treatment "write the authors
Drivers of choice
" In conclusion "argue Deguchi and colleagues" this study has revealed that 94% of patients with acute stroke with FANV received an ACO for the prevention of recurrent embolism, with approximately 87% of those patients who were prescribed a DOAC ".
"In contrast, patients taking warfarin on admission, those with a lower CCr value and those with severe sequelae upon discharge from the hospital were more likely to receive a prescription for warfarin, "write the authors. ] Giorgio Ottone
References:
Deguchi I, Tanahashi N, Takao M. Selection of oral anticoagulants in ischemic stroke patients with non-valvular atrial fibrillation. J Stroke Cerebrovasc Dis, 2018 June 30. doi: 10.1016 / j.jstrokecerebrovasdis.2018.05.036. [Epub ahead of print] read
Source link
