Hemorrhagic Transformation in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Time to Initiation of Oral Anticoagulant Therapy and Outcomes
Authors: Paciaroni Maurizio , Bandini Fabio , Agnelli Giancarlo , Tsivgoulis Georgios , Yaghi Shadi , Furie Karen L. , Tadi Prasanna , Becattini Cecilia , Zedde Marialuisa , Abdul‐Rahim Azmil H. , Lees Kennedy R. , Alberti Andrea , Venti Michele , Acciarresi Monica , D'Amore Cataldo , Mosconi Maria Giulia , Cimini Ludovica Anna , Altavilla Riccardo , Volpi Giacomo , Bovi Paolo , Carletti Monica , Rigatelli Alberto , Cappellari Manuel , Putaala Jukka , Tomppo Liisa , Tatlisumak Turgut , Marcheselli Simona , Pezzini Alessandro , Poli Loris , Padovani Alessandro , Masotti Luca , Vannucchi Vieri , Sohn Sung‐Il , Lorenzini Gianni , Tassi Rossana , Guideri Francesca , Acampa Maurizio , Martini Giuseppe , Ntaios George , Athanasakis George , Makaritsis Konstantinos , Karagkiozi Efstathia , Vadikolias Konstantinos , Liantinioti Chrissoula , Chondrogianni Maria , Mumoli Nicola , Consoli Domenico , Galati Franco , Sacco Simona , Carolei Antonio , Tiseo Cindy , Corea Francesco , Ageno Walter , Bellesini Marta , Colombo Giovanna , Silvestrelli Giorgio , Ciccone Alfonso , Lanari Alessia , Scoditti Umberto , Denti Licia , Mancuso Michelangelo , Maccarrone Miriam , Ulivi Leonardo , Orlandi Giovanni , Giannini Nicola , Gialdini Gino , Tassinari Tiziana , De Lodovici Maria Luisa , Bono Giorgio , Rueckert Christina , Baldi Antonio , D'Anna Sebastiano , Toni Danilo , Letteri Federica , Giuntini Martina , Lotti Enrico Maria , Flomin Yuriy , Pieroni Alessio , Kargiotis Odysseas , Karapanayiotides Theodore , Monaco Serena , Maimone Baronello Mario , Csiba Laszló , Szabó Lilla , Chiti Alberto , Giorli Elisa , Del Sette Massimo , Imberti Davide , Zabzuni Dorjan , Doronin Boris , Volodina Vera , Michel Patrik , Vanacker Peter , Barlinn Kristian , Pallesen Lars‐Peder , Barlinn Jessica , Deleu Dirk , Melikyan Gayane , Ibrahim Faisal , Akhtar Naveed , Gourbali Vanessa , Caso Valeria 
Published: December 2018

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.