Stroke severity in patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists.
Acute ischemic stroke
Anticoagulation
Atrial fibrillation
DOAC
NIHSS
Severity
Journal
Journal of neurology
ISSN: 1432-1459
Titre abrégé: J Neurol
Pays: Germany
ID NLM: 0423161
Informations de publication
Date de publication:
Sep 2019
Sep 2019
Historique:
received:
26
04
2019
accepted:
30
05
2019
revised:
28
05
2019
pubmed:
6
6
2019
medline:
29
1
2020
entrez:
6
6
2019
Statut:
ppublish
Résumé
Although direct oral anticoagulants (DOAC) have proven at least equally effective in the prevention of acute ischemic stroke (AIS) in patients with atrial fibrillation as compared to the vitamin K antagonists (VKA), no reliable data on the severity of AIS of DOAC patients as compared to VKA is available. Using a prospectively collected cohort of AIS patients, we performed univariate and multivariate (displayed as adjusted Odds Ratios, OR and 95% confidence intervals, 95% CI) analyses regarding the severity of AIS in patients with preceding DOAC (N = 210) versus VKA (N = 173) therapy. Additionally, we provide a sensitivity analysis considering only patients with warranted therapeutic anticoagulation activity. In a comprehensive stroke center population, the frequency of AIS under DOAC was multiple times higher than previously reported at around 6% of all AIS and steadily increasing. National Institute of Health Stroke Scale (NIHSS) in VKA patients (median 7, IQR 2-14) was equal to DOAC (median 5, IQR 2-16) on univariate analysis (P = 0.229). According to the multivariable linear logistic regression analysis adjusting for confounders of severe stroke, VKA was not significantly associated with higher NIHSS scores (β - 0.165, 95% CI - 1.874 to 1.545, P = 0.850) as compared to DOAC. Also in the sensitivity analysis considering only patients with warranted therapeutic OAC therapy, VKA was not significantly associated with higher NIHSS scores (β - 1.392, 95% CI - 3.506 to 0.721, P = 0.195) as compared to DOAC. However, VKA as compared to DOAC was significantly associated with lower rates of good functional outcome at three months (0.527, 95% CI 0.300-0.928), but not with increased mortality (aOR 1.825, 95% CI 0.780-4.273). Ischemic stroke in patients taking DOAC is an important and frequent scenario. Stroke severity in our real world population dataset is equal in patients taking VKA and DOAC, also in the case of warranted anticoagulation therapy. Preceding VKA as compared to DOAC was associated with lower rates of good functional outcome without excess mortality, but a causal relationship cannot be proven by our study design.
Sections du résumé
BACKGROUND
BACKGROUND
Although direct oral anticoagulants (DOAC) have proven at least equally effective in the prevention of acute ischemic stroke (AIS) in patients with atrial fibrillation as compared to the vitamin K antagonists (VKA), no reliable data on the severity of AIS of DOAC patients as compared to VKA is available.
METHODS
METHODS
Using a prospectively collected cohort of AIS patients, we performed univariate and multivariate (displayed as adjusted Odds Ratios, OR and 95% confidence intervals, 95% CI) analyses regarding the severity of AIS in patients with preceding DOAC (N = 210) versus VKA (N = 173) therapy. Additionally, we provide a sensitivity analysis considering only patients with warranted therapeutic anticoagulation activity.
FINDINGS
RESULTS
In a comprehensive stroke center population, the frequency of AIS under DOAC was multiple times higher than previously reported at around 6% of all AIS and steadily increasing. National Institute of Health Stroke Scale (NIHSS) in VKA patients (median 7, IQR 2-14) was equal to DOAC (median 5, IQR 2-16) on univariate analysis (P = 0.229). According to the multivariable linear logistic regression analysis adjusting for confounders of severe stroke, VKA was not significantly associated with higher NIHSS scores (β - 0.165, 95% CI - 1.874 to 1.545, P = 0.850) as compared to DOAC. Also in the sensitivity analysis considering only patients with warranted therapeutic OAC therapy, VKA was not significantly associated with higher NIHSS scores (β - 1.392, 95% CI - 3.506 to 0.721, P = 0.195) as compared to DOAC. However, VKA as compared to DOAC was significantly associated with lower rates of good functional outcome at three months (0.527, 95% CI 0.300-0.928), but not with increased mortality (aOR 1.825, 95% CI 0.780-4.273).
INTERPRETATION
CONCLUSIONS
Ischemic stroke in patients taking DOAC is an important and frequent scenario. Stroke severity in our real world population dataset is equal in patients taking VKA and DOAC, also in the case of warranted anticoagulation therapy. Preceding VKA as compared to DOAC was associated with lower rates of good functional outcome without excess mortality, but a causal relationship cannot be proven by our study design.
Identifiants
pubmed: 31165232
doi: 10.1007/s00415-019-09412-y
pii: 10.1007/s00415-019-09412-y
doi:
Substances chimiques
Anticoagulants
0
Vitamin K
12001-79-5
Types de publication
Comparative Study
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
2263-2272Références
N Engl J Med. 2003 Sep 11;349(11):1019-26
pubmed: 12968085
BMC Med Res Methodol. 2005 Apr 20;5:13
pubmed: 15840177
Stroke. 2009 Jun;40(6):2276-93
pubmed: 19423857
N Engl J Med. 2009 Sep 17;361(12):1139-51
pubmed: 19717844
N Engl J Med. 2011 Sep 8;365(10):883-91
pubmed: 21830957
N Engl J Med. 2011 Sep 15;365(11):981-92
pubmed: 21870978
Neurology. 2013 Aug 27;81(9):825-32
pubmed: 23902702
N Engl J Med. 2013 Nov 28;369(22):2093-104
pubmed: 24251359
Lancet. 2014 Mar 15;383(9921):955-62
pubmed: 24315724
Neurol Neurochir Pol. 2014;48(2):136-40
pubmed: 24821640
BMJ. 2016 Jun 16;353:i3189
pubmed: 27312796
Cerebrovasc Dis. 2016;42(5-6):415-420
pubmed: 27438461
Eur Heart J. 2016 Oct 7;37(38):2893-2962
pubmed: 27567408
Am J Med. 2016 Nov;129(11S):S73-S79
pubmed: 27568285
Pathology. 2016 Dec;48(7):712-719
pubmed: 27780603
BMJ. 2017 Feb 10;356:j510
pubmed: 28188243
JAMA. 2017 Mar 14;317(10):1057-1067
pubmed: 28291892
Europace. 2018 Apr 1;20(4):569-574
pubmed: 28460024
Int J Stroke. 2017 Oct;12(8):910-914
pubmed: 28585903
Clin Ther. 2017 Jul;39(7):1456-1478.e36
pubmed: 28668628
Eur J Neurol. 2017 Nov;24(11):1399-1406
pubmed: 28799181
J Thromb Haemost. 2018 Feb;16(2):209-219
pubmed: 29193737
Vasc Health Risk Manag. 2017 Dec 13;13:457-467
pubmed: 29263674
Eur J Neurol. 2018 May;25(5):747-e52
pubmed: 29360254
BMJ. 2018 Jul 4;362:k2505
pubmed: 29973392
J Stroke. 2018 Sep;20(3):321-331
pubmed: 30309227
Stroke. 2019 Apr;50(4):873-879
pubmed: 30852963
PLoS One. 2019 Mar 29;14(3):e0213379
pubmed: 30925155