Early Recurrence and Cerebral Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation
Authors: Paciaroni Maurizio , Agnelli Giancarlo , Falocci Nicola , Caso Valeria , Becattini Cecilia , Marcheselli Simona , Rueckert Christina , Pezzini Alessandro , Poli Loris , Padovani Alessandro , Csiba Laszló , Szabó Lilla , Sohn Sung-Il , Tassinari Tiziana , Abdul-Rahim Azmil H. , Michel Patrik , Cordier Maria , Vanacker Peter , Remillard Suzette , Alberti Andrea , Venti Michele , Scoditti Umberto , Denti Licia , Orlandi Giovanni , Chiti Alberto , Gialdini Gino , Bovi Paolo , Carletti Monica , Rigatelli Alberto , Putaala Jukka , Tatlisumak Turgut , Masotti Luca , Lorenzini Gianni , Tassi Rossana , Guideri Francesca , Martini Giuseppe , Tsivgoulis Georgios , Vadikolias Kostantinos , Liantinioti Chrissoula , Corea Francesco , Del Sette Massimo , Ageno Walter , De Lodovici Maria Luisa , Bono Giorgio , Baldi Antonio , D’Anna Sebastiano , Sacco Simona , Carolei Antonio , Tiseo Cindy , Acciarresi Monica , D’Amore Cataldo , Imberti Davide , Zabzuni Dorjan , Doronin Boris , Volodina Vera , Consoli Domenico , Galati Franco , Pieroni Alessio , Toni Danilo , Monaco Serena , Baronello Mario Maimone , Barlinn Kristian , Pallesen Lars-Peder , Kepplinger Jessica , Bodechtel Ulf , Gerber Johannes , Deleu Dirk , Melikyan Gayane , Ibrahim Faisal , Akhtar Naveed , Mosconi Maria Giulia , Bubba Valentina , Silvestri Ilenia , Lees Kennedy R. 
Published: July 2015

Background and Purpose—
The best time for administering anticoagulation therapy in acute cardioembolic stroke remains unclear. This prospective cohort study of patients with acute stroke and atrial fibrillation, evaluated (1) the risk of recurrent ischemic event and severe bleeding; (2) the risk factors for recurrence and bleeding; and (3) the risks of recurrence and bleeding associated with anticoagulant therapy and its starting time after the acute stroke.

Methods—
The primary outcome of this multicenter study was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding within 90 days from acute stroke.

Results—

Of the 1029 patients enrolled, 123 had 128 events (12.6%): 77 (7.6%) ischemic stroke or transient ischemic attack or systemic embolism, 37 (3.6%) symptomatic cerebral bleeding, and 14 (1.4%) major extracranial bleeding. At 90 days, 50% of the patients were either deceased or disabled (modified Rankin score ≥3), and 10.9% were deceased. High CHA
2
DS
2
-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesion and type of anticoagulant were predictive factors for primary study outcome. At adjusted Cox regression analysis, initiating anticoagulants 4 to 14 days from stroke onset was associated with a significant reduction in primary study outcome, compared with initiating treatment before 4 or after 14 days: hazard ratio 0.53 (95% confidence interval 0.30–0.93). About 7% of the patients treated with oral anticoagulants alone had an outcome event compared with 16.8% and 12.3% of the patients treated with low molecular weight heparins alone or followed by oral anticoagulants, respectively (
P
=0.003).

Conclusions—

Acute stroke in atrial fibrillation patients is associated with high rates of ischemic recurrence and major bleeding at 90 days. This study has observed that high CHA
2
DS
2
-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesions, and type of anticoagulant administered each independently led to a greater risk of recurrence and bleedings. Also, data showed that the best time for initiating anticoagulation treatment for secondary stroke prevention is 4 to 14 days from stroke onset. Moreover, patients treated with oral anticoagulants alone had better outcomes compared with patients treated with low molecular weight heparins alone or before oral anticoagulants.