Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study
Authors: Paciaroni Maurizio , Caso Valeria , Romoli Michele , Becattini Cecilia , Salerno Alexander , Rapillo Costanza , Simonnet Fanny , Strambo Davide , Canavero Isabella , Zedde Marialuisa , Pascarella Rosario , Sohn Sung-Il , Sacco Simona , Ornello Raffaele , Barlinn Kristian , Schoene Daniela , Rahmig Jan , Mosconi Maria Giulia , Leone De Magistris Ilaria , Alberti Andrea , Venti Michele , Silvestrelli Giorgio , Ciccone Alfonso , Padroni Marina , Laudisi Michele , Zini Andrea , Gentile Luana , Kargiotis Odysseas , Tsivgoulis Georgios , Tassi Rossana , Guideri Francesca , Acampa Maurizio , Masotti Luca , Grifoni Elisa , Rocco Alessandro , Diomedi Marina , Karapanayiotides Theodore , Engelter Stefan T , Polymeris Alexandros A , Zietz Annaelle , Bandini Fabio , Caliandro Pietro , Reale Giuseppe , Moci Marco , Zauli Aurelia , Cappellari Manuel , Emiliani Andrea , Gasparro Antonio , Terruso Valeria , Mannino Marina , Giorli Elisa , Toni Danilo , Andrighetti Marco , Falcou Anne , Palaiodimou Lina , Ntaios George , Sagris Dimitrios , Karagkiozi Efstathia , Adamou Anastasia , Halvatsiotis Panagiotis , Flomin Yuriy , Scoditti Umberto , Genovese Antonio , Popovic Nemanja , Pantoni Leonardo , Mele Francesco , Molitierno Nicola , Lochner Piergiorgio , Pezzini Alessandro , Del Sette Massimo , Sassos Davide , Giannopoulos Sotirios , Kosmidou Maria , Ntais Evangelos , Lotti Enrico Maria , Mastrangelo Vincenzo , Chiti Alberto , Naldi Andrea , Vanacker Peter , Ferrante Mario , Volodina Vera , Mancuso Michelangelo , Giannini Nicola , Baldini Marco , Vadikolias Kostantinos , Kitmeridou Sofia , Saggese Carlo Emanuele , Tassinari Tiziana , Saia Valentina , Michel Patrik 
Published: July 2023

Introduction: The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group). Patients and methods: For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days. Results: Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05–3.18; p = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84–3.47; p = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95–3.73; p = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95–2.85; p = 0.07). Conclusion: Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.