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Anticoagulation Therapy in Endovascular Thrombectomy Patients With Large-Vessel Occlusion Caused by Cardioembolism
Jae Beom Hong1,2, William K Diprose1,2, Michael T M Wang1
1Department of Medicine Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.
Insights
Adequate anticoagulation is lacking in many patients with cardioembolic stroke, increasing the need for endovascular thrombectomy (EVT). Optimizing oral anticoagulant (OAC) therapy could potentially prevent numerous EVT procedures.
Area of Science:
- Neurology
- Cardiology
- Vascular Medicine
Background:
- Cardioembolism, often from atrial fibrillation (AF), is a primary cause of ischemic stroke with large-vessel occlusion (LVO).
- Inadequate oral anticoagulant (OAC) therapy remains a significant challenge for patients with AF, mechanical heart valves, and other embolic sources.
- Endovascular thrombectomy (EVT) is a crucial treatment for LVO, but understanding pre-stroke OAC adequacy is vital.
Purpose of the Study:
- To assess the incidence of cardioembolic LVO in patients undergoing EVT.
- To evaluate the adequacy of OAC therapy in patients with cardioembolic LVO and a pre-stroke indication for anticoagulation.
- To determine the association between adequate OAC therapy and clinical outcomes following EVT.
Main Methods:
- Retrospective analysis of consecutive patients treated with EVT for cardioembolic LVO.
- Assessment of pre-stroke OAC indication and adequacy of anticoagulation.
- Evaluation of primary outcome (3-month functional independence) and secondary outcomes (neurological recovery, hemorrhage, mortality).
Main Results:
- Over half (53.1%) of EVT-treated patients had cardioembolic LVO, with atrial fibrillation being the most common cause.
- Only 27.7% of patients with a pre-stroke OAC indication were adequately anticoagulated at the time of LVO.
- Adequate anticoagulation was not associated with overall EVT outcomes but was linked to lower internal carotid artery occlusion rates and higher functional independence in prevalent AF patients.
Conclusions:
- A significant proportion of patients undergoing EVT for LVO have cardioembolic causes.
- Under-anticoagulation is prevalent among patients with cardioembolic LVO who have an indication for OACs.
- Improved OAC management could potentially reduce the need for EVT procedures in a substantial number of patients.
Background:
In patients with ischemic stroke, cardioembolism, predominantly caused by atrial fibrillation (AF), is a leading preventable cause of large-vessel occlusion (LVO). Despite proven efficacy, inadequate oral anticoagulant (OAC) therapy continues to be a major problem in patients with AF, mechanical heart valves, and other potential sources of emboli. We aimed to determine rates of cardioembolic LVO, the adequacy of OAC, and the association of OACs with clinical outcomes in patients with LVO treated with endovascular thrombectomy (EVT).
Methods:
Consecutive patients with cardioembolism treated with EVT were included and had pre-stroke indication for OACs and the adequacy of anticoagulation determined. The primary outcome was 3-month functional independence (modified Rankin Scale score 0-2). Secondary outcomes included early neurological recovery (reduction in National Institutes of Health Stroke Scale score ≥8 points, or score of 0-1 at 24 hours), symptomatic intracranial hemorrhage, and 3-month mortality and modified Rankin Scale score.
Results:
There were 784 patients treated with EVT, of whom 416 (53.1%; 231 men; mean±SD age, 67.1±15.9) had cardioembolic LVO. Of those with cardioembolism, 221 (53.1%) had prevalent AF, 99 (23.8%) incident AF, 48 (11.5%) mechanical heart valves, 10 (2.4%) left ventricular thrombus, and 38 (9.1%) other cardioembolic causes. A total of 242 patients were identified as having a pre-stroke indication for OACs, and 67 (27.7%) of these patients were considered adequately anticoagulated at time of LVO. In all 242 patients with cardioembolism with a pre-stroke indication for OACs, adequate anticoagulation was not associated with EVT outcomes. However, adequate anticoagulation in patients with prevalent AF was associated with lower rates of internal carotid artery occlusion (6.8% versus 18.9%; P=0.03) and higher rates of functional independence (odds ratio=1.94; 95% CI, 1.02-3.78]; P=0.04).
Conclusions:
Over half of patients treated with EVT were assessed as having a cardioembolic cause. Just over a quarter of patients with an indication for OACs at the time of LVO were adequately anticoagulated. These figures suggest that a substantial number of EVT procedures may have been avoided if more patients had been adequately anticoagulated.
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