Effect of anticoagulation on infarct volume and NIHSS score in patients with atrial fibrillation and ischaemic stroke

Yıl 2024, Cilt: 17 Sayı: 2, 315 - 323, 01.04.2024

Gökhan Aydoğan Alper Eren

https://doi.org/10.31362/patd.1359111

Öz

Purpose: The aim of this study was to evaluate the use of oral anticoagulation (OAC) in patients with cardioembolic stroke due to non-valvular atrial fibrillation (NVAF). The NIHSS (National Institute of Healt Stroke Scale) score calculated by a neurologist at initial presentation and infarct volume measured semi-automatically in cm3 by Magnetic Resonance Imaging (MRI).
Materials and methods: A total of 101 NVAF patients with acute ischaemic stroke were included in this retrospective study. Patients were divided into 4 groups according to OAC drug use: Non-OAC users (group 1), subtherapeutic dose warfarin users (under 70 years of age: INR≤2.0; over 70 years of age: INR≤1.6 group 2), therapeutic dose warfarin users (under 70 years of age: INR≥2.0; over 70 years of age: INR≥1.6 group 3) and therapeutic dose Non-vitamin K oral anticoagulant (NOAC) users group 4.
Results: Infarct volume was calculated as 22.20 cm³ median (0.4-235 cm³ lowest-highest) for group 1; 12.95 cm³ (1.3-129 cm³) for group 2; 2.25 cm³ (0.3-89 cm³) for group 3 and 4.40 cm³ (0.2-293 cm³) for group 4 and the difference was statistically significant (p=0.039). The calculated NIHSS score was 9 (4-23) for the group 1, 8.5 (3-18) for the group 2, 6.5 (2-20) for the group 3, 5 (1-22) for the group 4 and the effect of anticoagulation use on NIHSS score was statistically significant (p=0.029).
Conclusion: Anticoagulant treatment holds importance in the primary and secondary prevention of stroke and in enhancing the NIHSS score and infarct volumes among stroke patients, as evidenced in the current study.

Anahtar Kelimeler

Atrial fibrillation, cardioembolic stroke, ischemic stroke, infarct volume, NIHSS score

Atriyal fibrilasyon ve iskemik inme hastalarında antikoagülasyonun infarkt hacmi ve NIHSS skoru üzerine etkisi

Öz

Amaç: Bu çalışmada non-valvüler atrial fibrilasyona (NVAF) bağlı kardiyoembolik inme geçiren hastaların oral antikoagülasyon (OAK) kullanımının, ilk başvuruda nöroloji uzmanı tarafından hesaplanan NIHSS (National Institute of Healt Stroke Scale (Ulusal sağlık enstitüleri inme ölçeği)) skoru ve çekilen diffüzyon manyetik rezonans görüntüleme (MRG) ’nin cm3 cinsinden semiotomatik olarak ölçülen infarkt volümünün değerlendirilmesi amaçlanmıştır.
Gereç ve yöntem: Akut iskemik inme tanısı alan 101 NVAF hastası retrospektif olarak planlanan bu çalışmaya dahil edildi. Hastalar OAK ilaç kullanımına göre 4 gruba ayrıldı: OAK kullanmayanlar (grup 1), subterapötik dozda warfarin kullanan (70 yaş altı: INR≤2,0; 70 yaş üzeri: INR≤1,6 grup 2), terapötik dozda warfarin kullananlar (70 yaş altı: INR≥2,0; 70 yaş üzeri; INR≥1,6 grup 3) ve terapötik dozda Non-vitamin K oral antikoagülan (NOAK) kullanan grup 4 olmak üzere 4 gruba ayrıldı.
Bulgular: İnfarkt volümü 1. grup için 22,20 cm³ medyan: (0,4-235 cm³ en düşük-en yüksek), 2. grup: 12,95 cm³ (1,3-129 cm³), 3. grup: 2,25 cm³ 0,3-89 cm³) ve 4.grup: 4,40 cm³ (0,2-293 cm³) olarak hesaplandı ve aradaki fark istatistiksel olarak anlamlıydı (p=0,039). Hesaplanan NIHSS skoru 1. grup için 9 (4-23), 2. grup: 8,5 (3-18), 3. grup: 6,5 (2-20), 4.grup 5 (1-22) olarak hesaplandı ve antikoagülasyon kullanımının NIHSS skoru üzerine etkisi istatistiksel olarak anlamlı bulundu (p=0,029).
Sonuç: Antikoagülan tedavi, bu çalışmada gösterildiği gibi inme hastalarında NIHSS skorunu ve enfarktüs hacimlerini iyileştirmenin yanı sıra inmenin birincil ve ikincil önlenmesinde önemlidir.

Anahtar Kelimeler

Atrial fibrilasyon, kardioembolik inme, iskemik inme, infarkt volümü, NIHSS skoru

Kaynakça

• 1. Utku U, Çelik Y. Etiology, classification and risk factors in stroke. Cerebrovascular Diseases. 1st ed. Ankara: Güneş Medical Bookstores, 2009;51-71.
• 2. Kaya E. Evaluation of atrial and ventricular functions with echocardiography in embolic stroke of undetermined source. Uzmanlık Tezi. Pamukkale Üniversitesi, Sağlık Bilimler Enstitüsü, Kardiyoloji Anabilim Dalı, Denizli, 2018.
• 3. Fuster V, Rydén LE, Cannom DS. et al. Guidelines for the management of patients with atrial fibrillation. Executive summary. Rev Esp Cardiol 2006;59:1329.
• 4. Fitzmaurice D. Atrial fibrillation and coagulation: who and when? Blood Rev 2009;23:241-244. https://doi.org/10.1016/j.blre.2009.07.006
• 5. Marini C, de Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: Results from a population-based study. Stroke 2005;36:1115-1119. https://doi.org/10.1161/01.STR.0000166053.83476.4a
• 6. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. Jama 2001;285:2864-2870. https://doi.org/10.1001/jama.285.22.2864
• 7. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of Cardiology/American heart association task force on practice guidelines and the heart rhythm society. J Am Coll Cardiol 2014;64:1-76. https://doi.org/10.1161/CIR.0000000000000040
• 8. Lip GYH, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke 2010;41:2731-2738. https://doi.org/10.1161/STROKEAHA.110.590257
• 9. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137:263-272. https://doi.org/10.1378/chest.09-1584
• 10. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. The Lancet 2014;383:955-962. https://doi.org/10.1016/S0140-6736(13)62343-0 11. Camm AJ, Lip GYH, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719-2747. https://doi.org/10.1093/eurheartj/ehs253
• 12. Birman Deych E, Radford MJ, Nilasena DS, Gage BF. Use and effectiveness of warfarin in medicare beneficiaries with atrial fibrillation. Stroke 2006;37:1070-1074. https://doi.org/10.1161/01.STR.0000208294.46968.a4
• 13. Hylek EM, Evans Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007;115:2689-2696. https://doi.org/10.1161/CIRCULATIONAHA.106.653048
• 14. Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis 2006;22:389-395. https://doi.org/10.1159/000094857
• 15. Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604-607. https://doi.org/10.1161/01.STR.19.5.604
• 16. Bamford J, Sandercock P, Dennis M, Warlow C, Burn JJTL. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991;337:1521-1526. https://doi.org/10.1016/0140-6736(91)93206-O
• 17. Sakamoto Y, Okubo S, Sekine T, Nito C, Suda S, Matsumoto N, et al. Prior direct oral anticoagulant therapy is related to small infarct volume and no major artery occlusion in patients with stroke and non-valvular atrial fibrillation. JAHA 2018;7:e009507. https://doi.org/10.1161/JAHA.118.009507
• 18. Kim J S, Lee KB, Roh H, Ahn MY, Hwang HW. Gender differences in the functional recovery after acute stroke. J Clin Neurol 2010;6:183-188. https://doi.org/10.3988/jcn.2010.6.4.183
• 19. Berger C, Fiorelli M, Steiner T, et al. Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 2001;32:1330-1335. https://doi.org/10.1161/01.STR.32.6.1330
• 20. Dietzel J, Piper SK, Ruschmann R, et al. Impact of pre-admission oral anticoagulation on ischaemic stroke volume, lesion pattern, and frequency of intracranial arterial occlusion in patients with atrial fibrillation. EP Europace 2018;20:1758-1765, https://doi.org/10.1093/europace/eux333
• 21. Szymanski FM, Lip GY, Filipiak KJ, Platek AE, Hrynkiewicz Szymanska A, Opolski G. Stroke risk factors beyond the CHA2DS2-VASc score: can we improve our identification of “high stroke risk” patients with atrial fibrillation? The American Journal of Cardiology 2015;116:1781-1788. https://doi.org/10.1016/j.amjcard.2015.08.049
• 22. Olesen JB, Fauchier L, Lane DA, Taillandier S, Lip GY. Risk factors for stroke and thromboembolism in relation to age among patients with atrial fibrillation: the loire valley atrial fibrillation project. Chest 2012;141:147-153. https://doi.org/10.1378/chest.11-0862
• 23. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021;42:373-498. https://doi.org/10.1093/eurheartj/ehaa612
• 24. Marzona I, Proietti M, Farcomeni A, et al. Sex differences in stroke and major adverse clinical events in patients with atrial fibrillation: A systematic review and meta-analysis of 993,600 patients. International Journal of Cardiology 2018;269:182-191. https://doi.org/10.1016/j.ijcard.2018.07.044
• 25. Nielsen PB, Skjøth F, Overvad TF, Larsen TB, Lip GYH. Female sex is a risk modifier rather than a risk factor for stroke in atrial fibrillation: should we use a CHA2DS2-VA score rather than CHA2DS2-VASc? Circulation 2018;137:832-840. https://doi.org/10.1161/CIRCULATIONAHA.117.029081
• 26. Giralt Steinhauer E, Cuadrado Godia E, Ois A, et al. CHA2DS2-VASc score and prognosis in ischemic strokes with atrial fibrillation. J Neurol 2012;259:745-751. https://doi.org/10.1007/s00415-011-6259-7
• 27. Van Latum JC. European atrial fibrillation trial: secondary prevention in non-rheumatic atrial fibrillation. Erasmus University Rotterdam. Available at: http://hdl.handle.net/1765/21432. Accessed January 4, 1995
• 28. Hoyer C, Filipov A, Neumaier Probst E, Szabo K, Ebert A, Alonso A. Impact of pre-admission treatment with non-vitamin K oral anticoagulants on stroke severity in patients with acute ischemic stroke. J Thromb Thrombolysis 2018;45:529-535. https://doi.org/10.1007/s11239-018-1634-1
• 29. Beaulieu C, De Crespigny A, Tong DC, Moseley ME, Albers GW, Marks MP. Longitudinal magnetic resonance imaging study of perfusion and diffusion in stroke: evolution of lesion volume and correlation with clinical outcome. Ann Neurol 1999;46:568-578. https://doi.org/10.1002/1531-8249(199910)46:4<568::aid-ana4>3.0.co;2-r
• 30. Löuvbld KO, Baird AE, Schlaug G, et al. Ischemic lesion volumes in acute stroke by diffusion-weighted magnetic resonance imaging correlate with clinical outcome. Ann Neurol 1997;42:164-170. https://doi.org/10.1002/ana.410420206
• 31. Kim BJ, Kim HJ, Do Y, et al. The impact of prior antithrombotic status on cerebral infarction in patients with atrial fibrillation. J Stroke Cerebrovasc Dis 2014;23:2054-2059. https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.03.011
• 32. Terruso V, D’Amelio M, Di Benedetto N, Lupo I, Saia V, Famoso G, Mazzola MA, Aridon P, Sarno C, Ragonese P, Savettieri G. Frequency and determinants for hemorrhagic transformation of cerebral infarction. Neuroepidemiology 2009;33:261-265. https://doi.org/10.1159/000229781