Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease (Nov 2018)

Hemorrhagic Transformation in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Time to Initiation of Oral Anticoagulant Therapy and Outcomes

  • Maurizio Paciaroni,
  • Fabio Bandini,
  • Giancarlo Agnelli,
  • Georgios Tsivgoulis,
  • Shadi Yaghi,
  • Karen L. Furie,
  • Prasanna Tadi,
  • Cecilia Becattini,
  • Marialuisa Zedde,
  • Azmil H. Abdul‐Rahim,
  • Kennedy R. Lees,
  • Andrea Alberti,
  • Michele Venti,
  • Monica Acciarresi,
  • Cataldo D'Amore,
  • Maria Giulia Mosconi,
  • Ludovica Anna Cimini,
  • Riccardo Altavilla,
  • Giacomo Volpi,
  • Paolo Bovi,
  • Monica Carletti,
  • Alberto Rigatelli,
  • Manuel Cappellari,
  • Jukka Putaala,
  • Liisa Tomppo,
  • Turgut Tatlisumak,
  • Simona Marcheselli,
  • Alessandro Pezzini,
  • Loris Poli,
  • Alessandro Padovani,
  • Luca Masotti,
  • Vieri Vannucchi,
  • Sung‐Il Sohn,
  • Gianni Lorenzini,
  • Rossana Tassi,
  • Francesca Guideri,
  • Maurizio Acampa,
  • Giuseppe Martini,
  • George Ntaios,
  • George Athanasakis,
  • Konstantinos Makaritsis,
  • Efstathia Karagkiozi,
  • Konstantinos Vadikolias,
  • Chrissoula Liantinioti,
  • Maria Chondrogianni,
  • Nicola Mumoli,
  • Domenico Consoli,
  • Franco Galati,
  • Simona Sacco,
  • Antonio Carolei,
  • Cindy Tiseo,
  • Francesco Corea,
  • Walter Ageno,
  • Marta Bellesini,
  • Giovanna Colombo,
  • Giorgio Silvestrelli,
  • Alfonso Ciccone,
  • Alessia Lanari,
  • Umberto Scoditti,
  • Licia Denti,
  • Michelangelo Mancuso,
  • Miriam Maccarrone,
  • Leonardo Ulivi,
  • Giovanni Orlandi,
  • Nicola Giannini,
  • Gino Gialdini,
  • Tiziana Tassinari,
  • Maria Luisa De Lodovici,
  • Giorgio Bono,
  • Christina Rueckert,
  • Antonio Baldi,
  • Sebastiano D'Anna,
  • Danilo Toni,
  • Federica Letteri,
  • Martina Giuntini,
  • Enrico Maria Lotti,
  • Yuriy Flomin,
  • Alessio Pieroni,
  • Odysseas Kargiotis,
  • Theodore Karapanayiotides,
  • Serena Monaco,
  • Mario Maimone Baronello,
  • Laszló Csiba,
  • Lilla Szabó,
  • Alberto Chiti,
  • Elisa Giorli,
  • Massimo Del Sette,
  • Davide Imberti,
  • Dorjan Zabzuni,
  • Boris Doronin,
  • Vera Volodina,
  • Patrik Michel,
  • Peter Vanacker,
  • Kristian Barlinn,
  • Lars‐Peder Pallesen,
  • Jessica Barlinn,
  • Dirk Deleu,
  • Gayane Melikyan,
  • Faisal Ibrahim,
  • Naveed Akhtar,
  • Vanessa Gourbali,
  • Valeria Caso

DOI
https://doi.org/10.1161/JAHA.118.010133
Journal volume & issue
Vol. 7, no. 22

Abstract

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Background In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation (HT). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT, (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT. Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3–8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0–6.0) of those without HT; 53.1% of patients with HT were deceased or disabled compared with 35.8% of those without HT. On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24–2.35). Conclusions In patients with HT, anticoagulation was initiated about 12 days later than patients without HT. This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability.

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