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  • 1
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    Online Resource
    Internal Carotid Artery Tortuosity: Impact on Mechanical Thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 8 ( 2022-08), p. 2458-2467
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 8 ( 2022-08), p. 2458-2467
    Abstract: Although tortuosity of the internal carotid artery (ICA) can pose a significant challenge when performing mechanical thrombectomy, few studies have examined the impact of ICA tortuosity on mechanical thrombectomy outcomes. Methods: In a registry-based hospital cohort, consecutive patients with anterior circulation stroke in whom mechanical thrombectomy was attempted were divided into 2 groups: those with tortuosity in the extracranial or cavernous ICA (tortuous group) and those without (nontortuous group). The extracranial ICA tortuosity was defined as the presence of coiling or kinking. The cavernous ICA tortuosity was defined by the posterior deflection of the posterior genu or the shape resembling Simmons-type catheter. Outcomes included first pass effect (FPE; extended Thrombolysis in Cerebral Infarction score 2c/3 after first pass), favorable outcome (3-month modified Rankin Scale score of 0–2), and intracranial hemorrhage. Results: Of 370 patients, 124 were in the tortuous group (extracranial ICA tortuosity, 35; cavernous ICA tortuosity, 70; tortuosity at both sites, 19). The tortuous group showed a higher proportion of women and atrial fibrillation than the nontortuous group. FPE was less frequently achieved in the tortuous group than the nontortuous group (21% versus 39%; adjusted odds ratio, 0.45 [95% CI, 0.26–0.77]). ICA tortuosity was independently associated with the longer time from puncture to extended Thrombolysis in Cerebral Infarction ≥2b reperfusion (β=23.19 [95% CI, 13.44–32.94] ). Favorable outcome was similar between groups (46% versus 48%; P =0.87). Frequencies of any intracranial hemorrhage (54% versus 42%; adjusted odds ratio, 1.61 [95% CI, 1.02–2.53]) and parenchymal hematoma (11% versus 6%; adjusted odds ratio, 2.41 [95% CI, 1.04–5.58] ) were higher in the tortuous group. In the tortuous group, the FPE rate was similar in patients who underwent combined stent retriever and contact aspiration thrombectomy and in those who underwent either procedure alone (22% versus 19%; P =0.80). However, in the nontortuous group, the FPE rate was significantly higher in patients who underwent combined stent retriever and contact aspiration (52% versus 35%; P =0.02). Conclusions: ICA tortuosity was independently associated with reduced likelihood of FPE and increased risk of postmechanical thrombectomy intracranial hemorrhage. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.037904
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 2
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    The bleeding with antithrombotic therapy study 2: Rationale, design, and baseline characteristics of the participants
    SAGE Publications ; 2020
    In:  European Stroke Journal Vol. 5, No. 4 ( 2020-12), p. 423-431
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 5, No. 4 ( 2020-12), p. 423-431
    Abstract: The bleeding risk of current antithrombotic strategies in clinical settings, including recently developed agents, needs to be clarified. Methods and Design In an investigator-initiated, prospective, multicentre, observational study, patients with cerebrovascular or cardiovascular diseases who were taking oral antiplatelet or anticoagulant agents were enrolled. Compulsory multimodal magnetic resonance images were acquired at baseline to assess cerebral small vessel disease. Six-month follow-up will be performed for two years. The primary outcome is major bleeding as defined by the International Society on Thrombosis and Hemostasis. Results Between October 2016 and March 2019, 5306 patients (71.7 ± 11.2 years old, 1762 women) were enrolled. Previous intracranial haemorrhage was documented in 181 patients (3.4%), cerebrovascular disease (including asymptomatic) requiring antithrombotic therapy in 5006 patients (94.3%), and atrial fibrillation in 1061 patients (20.0%). At entry, 3726 patients (70.2%) were taking antiplatelet agents alone, including 551 (10.4%) using dual antiplatelet agents, 1317 (24.8%) taking anticoagulants alone, and the remaining 263 (5.0%) taking both. The leading antiplatelet agent was clopidogrel (2014 patients), and the leading combination of dual antiplatelet medication was clopidogrel plus aspirin (362). Use of direct oral anticoagulants (1029 patients, 19.4%) exceeded warfarin use (554, 10.4%). The number of pivotal bleeding events exceeded 200 in April 2020. Conclusions This study is expected to provide the incidence of bleeding complications of recent oral antithrombotics in clinical practice and identify their associations with underlying small vessel disease and other biomarkers. Novel risk stratification models for bleeding risk will be able to be created based on the study results.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/2396987320960618
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
    detail.hit.zdb_id: 2851287-X
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  • 3
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    Impact of Renal Impairment on Intensive Blood-Pressure–Lowering Therapy and Outcomes in Intracerebral Hemorrhage : Results From ATACH-2
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Neurology Vol. 97, No. 9 ( 2021-08-31), p. e913-e921
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 97, No. 9 ( 2021-08-31), p. e913-e921
    Abstract: The clinical effect of renal impairment on intracerebral hemorrhage (ICH) is unknown. This study sought to assess whether estimated glomerular filtration rate (eGFR) affects clinical outcomes or modifies the efficacy of intensive systolic blood pressure (BP) control (target, 110–139 mm Hg) against the standard (target, 140–179 mm Hg) among patients with ICH. Methods We conducted post hoc analyses of ATACH-2, a randomized, 2-group, open-label trial. The baseline eGFR of each eligible patient was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The outcome of interest was death or disability at 90 days. Multivariate logistic regression models were used for analysis. Results Among the 1,000 patients randomized, 974 were analyzed. The median baseline eGFR was 88 (interquartile range, 68, 99) mL/min/1.73 m 2 ; 451 (46.3%), 363 (37.3%), and 160 (16.4%) patients had baseline eGFR values of ≥90, 60–89, and 〈 60 mL/min/1.73 m 2 , respectively. Compared with normal eGFR (≥90 mL/min/1.73 m 2 ), higher odds of death or disability were noted among those with eGFR values of 〈 60 mL/min/1.73 m 2 (adjusted odds ratio [OR], 2.02; 95% confidence interval [CI] , 1.25–3.26) but not among those with eGFR values of 60–89 mL/min/1.73 m 2 (OR, 1.01; 95% CI, 0.70–1.46). The odds of death or disability were significantly higher in the intensive arm among patients with decreased eGFR; the ORs were 0.89 (95% CI, 0.55–1.44), 1.13 (0.68–1.89), and 3.60 (1.47–8.80) in patients with eGFR values of ≥90, 60–89, and 〈 60 mL/min/1.73 m 2 , respectively ( p for interaction = 0.02). Discussion Decreased eGFR is associated with unfavorable outcomes following ICH. The statistically significant interaction between the eGFR group and treatment assignment raised safety concerns for the intensive BP-lowering therapy among patients with renal impairment. Trial Registration Information Clinicaltrials.gov identifier: NCT01176565. Classification of Evidence This study provides Class II evidence that in spontaneous ICH, decreased eGFR identifies patients at risk of death or disability following intensive BP control.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000012442
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 4
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    Stent Retriever or Aspiration Catheter Alone vs Their Combination as the First-Line Thrombectomy in Acute Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Neurosurgery Vol. 92, No. 1 ( 2023-01), p. 159-166
    Details
    In: Neurosurgery, Ovid Technologies (Wolters Kluwer Health), Vol. 92, No. 1 ( 2023-01), p. 159-166
    Type of Medium: Online Resource
    ISSN: 0148-396X , 1524-4040
    URL: Article
    DOI: 10.1227/neu.0000000000002167
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 1491894-8
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  • 5
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    Heart‐Brain Team Approach of Acute Myocardial Infarction Complicating Acute Stroke: Characteristics of Guideline‐Recommended Coronary Revascularization and Antithrombotic Therapy and Cardiovascular and Bleeding Outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Journal of the American Heart Association Vol. 12, No. 2 ( 2023-01-17)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 12, No. 2 ( 2023-01-17)
    Abstract: Acute myocardial infarction (AMI) infrequently occurs after acute stroke. The Heart‐brain team approach has a potential to appropriately manage this poststroke cardiovascular complication. However, clinical outcomes of AMI complicating acute stroke (AMI‐CAS) with the heart‐brain team approach have not been characterized. The current study investigated cardiovascular outcomes in patients with AMI‐CAS managed by a heart‐brain team. Methods and Results We retrospectively analyzed 2390 patients with AMI at our institute (January 1, 2007–September 30, 2020). AMI‐CAS was defined as the occurrence of AMI within 14 days after acute stroke. Major adverse cerebral/cardiovascular events (cardiac‐cause death, nonfatal myocardial infarction, and nonfatal stroke) and major bleeding events were compared in subjects with  AMI‐CAS and those without acute stroke. AMI‐CAS was identified in 1.6% of the subjects. Most AMI‐CASs (37/39=94.9%) presented ischemic stroke. Median duration of AMI from the onset of acute stroke was 2 days. Patients with AMI‐CAS less frequently received primary percutaneous coronary intervention (43.6% versus 84.7%; P 〈 0.001) and dual‐antiplatelet therapy (38.5% versus 85.7%; P 〈 0.001), and 33.3% of them did not receive any antithrombotic agents (versus 1.3%; P 〈 0.001). During the observational period (median, 2.4 years [interquartile range, 1.1–4.4 years]), patients with AMI‐CAS exhibited a greater likelihood of experiencing major adverse cerebral/cardiovascular events (hazard ratio [HR] , 3.47 [95% CI, 1.99–6.05]; P 〈 0.001) and major bleeding events (HR, 3.30 [95% CI, 1.34–8.10]; P =0.009). These relationships still existed even after adjusting for clinical characteristics and medication use (major adverse cerebral/cardiovascular event: HR, 1.87 [95% CI, 1.02–3.42]; P =0.04; major bleeding: HR, 2.67 [95% CI, 1.03–6.93]; P =0.04). Conclusions Under the heart‐brain team approach, AMI‐CAS was still a challenging disease, reflected by less adoption of primary percutaneous coronary intervention and antithrombotic therapies, with substantially elevated cardiovascular and major bleeding risks. Our findings underscore the need for a further refined approach to mitigate their ischemic/bleeding risks.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.122.027156
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 6
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    Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Journal of the American Heart Association Vol. 11, No. 19 ( 2022-10-04)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 11, No. 19 ( 2022-10-04)
    Abstract: We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset. Methods and Results Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P =0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P =0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months. Conclusions Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.122.025809
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 7
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    Mechanical Thrombectomy Up to 24 Hours in Large Vessel Occlusions and Infarct Velocity Assessment
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Journal of the American Heart Association Vol. 10, No. 24 ( 2021-12-21)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 10, No. 24 ( 2021-12-21)
    Abstract: We retrospectively compared early‐ ( 〈 6 hours) versus late‐ (6–24 hours) presenting patients using perfusion‐weighted imaging selection and evaluated clinical/radiographic outcomes. Methods and Results Large vessel occlusion patients treated with mechanical thrombectomy from August 2017 to July 2020 within 24 hours of onset were retrieved from a single‐center database. Perfusion‐weighted imaging was analyzed by automated software and final infarct volume was measured semi‐automatically within 14 days. The primary end point was good outcome (modified Rankin Scale 0–2 at 90 days). Secondary end points were excellent outcome (modified Rankin Scale 0–1 at 90 days), symptomatic intracranial hemorrhage, and death. Clinical characteristics/radiological values including hypoperfusion volume and infarct growth velocity (baseline volume/onset‐to‐image time) were compared between the groups. Of 1294 patients, 118 patients were included. The median age was 74 years, baseline National Institutes of Health Stroke Scale score was 14, and core volume was 13 mL. The late‐presenting group had more female patients (67% versus 31%, respectively; P =0.001). No statistically significant differences were seen in good outcome (42% versus 53%, respectively; P =0.30), excellent outcome (26% versus 32%, respectively; P =0.51), symptomatic intracranial hemorrhage (6.5% versus 4.6%, respectively; P =0.74), and death (3.2% versus 5.7%, respectively; P =0.58) between the groups. The late‐presenting group had more atherothrombotic cerebral infarction (19% versus 6%, respectively; P =0.03), smaller hypoperfusion volume (median: 77 versus 133 mL, respectively; P =0.04), and slower infarct growth velocity (median: 0.6 versus 5.1 mL/h, respectively; P =0.03). Conclusions Patients with early‐ and late‐time windows treated with mechanical thrombectomy by automated perfusion‐weighted imaging selection have similar outcomes, comparable with those in randomized trials, but different in infarct growth velocities. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.121.022880
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 8
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    Impact of the RNF213 p.R4810K Variant on Endovascular Therapy for Large‐Vessel Occlusion Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke: Vascular and Interventional Neurology Vol. 2, No. 6 ( 2022-11)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 2, No. 6 ( 2022-11)
    Abstract: We investigated the impact of the ring finger protein 213 p.R4810K variant, a founder variant for moyamoya disease in East Asians, on endovascular therapy outcomes in patients with acute anterior‐circulation large‐vessel occlusion stroke in comparison with noncarriers. Methods Of the consecutive patients with ischemic stroke admitted to our institute from 2011 to 2021, patients who underwent endovascular therapy for acute occlusion of the intracranial internal carotid artery or M1 segment of the middle cerebral artery were included. Outcomes were instant reocclusion, final modified Thrombolysis in Cerebral Infarction reperfusion ≥2b, and early reocclusion. Instant reocclusion was defined as the occurrence of reocclusion during the procedure, and early reocclusion was defined as reocclusion detected on magnetic resonance angiography within 2 weeks after the confirmation of successful reperfusion. Results Of the 277 patients analyzed (128 women; median age, 76 years), 10 patients (3.6%) carried the ring finger protein 213 p.R4810K variant. Variant carriers were younger ( P =0.01) and more frequently had intracranial atherosclerotic disease‐related large‐vessel occlusion as a cause of acute large‐vessel occlusion ( P 〈 0.001) compared with noncarriers. Variant carriers showed a higher rate of instant reocclusion (70.0% versus 5.6%; P 〈 0.001), but there were no significant intergroup differences in the final modified Thrombolysis in Cerebral Infarction ≥2b reperfusion rate between carriers and noncarriers (100.0% versus 81.6%, respectively; P =0.22). Early reocclusion was more frequent in variant carriers compared with noncarriers (60.0% versus 0.4%; P 〈 0.001). Conclusions Instant and early reocclusions were more frequent in variant carriers who underwent endovascular therapy for acute anterior‐circulation large‐vessel occlusion compared with noncarriers.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.122.000396
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 3144224-9
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  • 9
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    Abstract TMP87: Thrombus Age in Ischemic Stroke With Atrial Fibrillation
    Ovid Technologies (Wolters Kluwer Health) ; 2024
    In:  Stroke Vol. 55, No. Suppl_1 ( 2024-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 55, No. Suppl_1 ( 2024-02)
    Abstract: Background and purpose: Because the biochemical composition of thrombus changes after formation over time, thrombus maturation in the left atrium may affect clot compositions in ischemic stroke with atrial fibrillation (AF). We aimed to investigate the association of the age of retrieved thrombi with clinical features and outcomes after MT for ischemic stroke with AF. Methods: We retrospectively reviewed consecutive patients with ischemic stroke with known AF or AF diagnosed after stroke onset who underwent MT and whose retrieved thrombi were pathologically analyzed. Thrombi were classified as fresh ( 〈 1 day) and older (1-5 days) based on the areas (≤20 % or 〉 20 %) of lytic features of granulocytes in the section. Components of thrombi were quantified using immunostaining. Outcomes included first pass effect (FPE, extended Thrombolysis in Cerebral Infarction [eTICI] 2c/3 after first pass) and favorable outcome (3-month modified Rankin Scale score of 0 to 2 or equal to premorbid mRS score). Results: Of 168 patients, 62 patients (37%) had older thrombi. The presence of older thrombi was independently associated with the higher CHADS 2 score (adjusted OR [aOR], 1.46; 95% confidence interval [CI] , 1.07-1.99). Older thrombi had the higher proportion of fibrin, platelets, von Willebrand factor, and neutrophil extracellular traps than fresh thrombi. FPE was less frequently achieved in patients with older thrombi than those with fresh thrombi (21% versus 43%; aOR, 0.36; 95% CI, 0.17-0.77). Favorable outcomes were fewer in patients with older thrombi than those with fresh thrombi (40% versus 73%; aOR, 0.37; 95% CI, 0.16-0.85). Conclusions: In patients with ischemic stroke with AF, older thrombi was associated with cardiovascular risk factors and included abundant amounts of components associated with the thrombectomy resistance. Patients with older thrombi had poorer functional outcomes presumably due to concomitant risk factors and worse revascularization outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.TMP87
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
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  • 10
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    Early Initiation of Direct Oral Anticoagulants After Onset of Stroke and Short- and Long-Term Outcomes of Patients With Nonvalvular Atrial Fibrillation
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. 3 ( 2020-03), p. 883-891
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. 3 ( 2020-03), p. 883-891
    Abstract: We aimed to compare outcomes of ischemic stroke patients with nonvalvular atrial fibrillation between earlier and later initiation of direct oral anticoagulants (DOACs) after stroke onset. Methods— From data for 1192 nonvalvular atrial fibrillation patients with acute ischemic stroke or transient ischemic attack in a prospective, multicenter, observational study, patients who started DOACs during acute hospitalization were included and divided into 2 groups according to a median day of DOAC initiation after onset. Outcomes included stroke or systemic embolism, major bleeding, and death at 3 months, as well as those at 2 years. Results— DOACs were initiated during acute hospitalization in 499 patients in median 4 (interquartile range, 2–7) days after onset. Thus, 223 patients (median age, 74 [interquartile range, 68–81] years; 78 women) were assigned to the early group (≤3 days) and 276 patients (median age, 75 [interquartile range, 69–82] years; 101 women) to the late (≥4 days) group. The early group had lower baseline National Institutes of Health Stroke Scale score and smaller infarcts than the late group. The rate at which DOAC administration persisted at 2 years was 85.2% overall, excluding patients who died or were lost to follow-up. Multivariable Cox shared frailty models showed comparable hazards between the groups at 2 years for stroke or systemic embolism (hazard ratio, 0.86 [95% CI, 0.47–1.57]), major bleeding (hazard ratio, 1.39 [95% CI, 0.42–4.60] ), and death (hazard ratio, 0.61 [95% CI, 0.28–1.33]). Outcome risks at 3 months also did not significantly differ between the groups. Conclusions— Risks for events including stroke or systemic embolism, major bleeding, and death were comparable whether DOACs were started within 3 days or from 4 days or more after the onset of nonvalvular atrial fibrillation–associated ischemic stroke or transient ischemic attack. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01581502.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.119.028118
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 1467823-8
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