Journal Club - Aseel

Early versus late anticoagulation for ischaemic
stroke associated with atrial fibrillation:

multicentre Cohort study
objectives :
- To encourage read the articles, papers and studies
- To appraise papers critically

- to Promotes evidence-based practice
-To Develops leadership and presentation skills
- Finally to have fun!!

table of content :
introduction methodes
statistical methods Result

introduction :
Aim of the study :
Is to describe the timing of OAC usage in a prospective multicenter cohort observational study
of adult patients with acute ischemic stroke or TIA who started on OAC for either known or
new onset AF.
They dichotomized according to their timing on starting OAC into :

early from day 0 to day 4
versus
late from day 5 to day 90 or never started
non-valvular AF and ischemic stroke:
Non-valvular atrial fibrillation isn't caused by a problem with a heart valve.
Atrial fibrillation (AF) is associated with up to a five-fold increased risk of stroke, and the risk of
early recurrence is high.
are more often disabling or fatal than other types, with longer hospital stays and higher costs,
so preventing early recurrence is a key clinical challenge.
Challenges in OAC:
The OAC is highly effective for long-term stroke prevention in AF. But the safety and net benefit
of acute AF-related strokes have not been established.
Initiation of OAC in the first few days after stroke could prevent ischemic stroke recurrence but
might increase the risk by fivefold of ICH, including hemorrhagic transformation of the infarct.
introduction :
what is done before : there were an observational studies ( including patients treated with warfarin or
other vitamin K antagonists) reported an 8%–10% risk of recurrent ischemic stroke and a 2%–4% risk of
symptomatic ICH within 90 days of AF-related ischemic stroke.
Guideline : guidelines do not provide clear recommendations on the timing of OAC after acute AF-related
stroke.
The European Society UK guidelines for observational CT-

US guidelines
of Cardiology OAC recommended based suggesting
suggest that delay for 2 week that most
guidelines
recommend starting commencing period for haemorrhagic
OAC according to OAC within 14 ‘disabling’ stroke transformation HT
infarct size at 1, 3, 6 or days is and started ‘no occurs within 14 days
12 days based only on later than 14 days’ of an ischaemic
reasonable.
expert consensus. for other strokes stroke.
methods :
study design : post hoc multicenter, prospective inception observational study.
study population : Participants were recruited from 79 hospitals throughout the UK and
one hospital in the Netherlands as part of the Clinical Relevance Of Microbleeds In Stroke-2
study (CROMIS-2).
methods :
outcome : The primary outcome was defined as a composite of ischemic stroke,
TIA, ICH or death due to any cause within 90 days of the qualifying ischemic event.
inclusion: Patients were included if they presented with an ischemic stroke or TIA,
had AF and were suitable for OAC ( according to their treating physician )
and if accurate information on the timing of OAC administration was available.
exclusion : Patients were excluded if they had previously been exposed to OAC or
the exact date of anticoagulation was unknown .
methodes :
Imaging studies :
small vessel occlusion criteria (defined as single small <15 mm (DWI) infarctions within the MCA
distribution or the pons) and for infarct size (defined as greater or less than one-third of a
vascular territory).
- hemorrhagic transformation :
rated using the European Cooperative Acute Stroke Study (ECASS) criteria.
- Cerebral microbleeds and white matter hyperintensities (WMHs) :
Fazekas scale; a score of 2 or above in either a periventricular or deep white matter region was
considered moderate to severe.
Statistics :
1) if normally distributed: t-test.
2) if not not normally distributed: Mann-Whitney U test .
3) categorical variables between the groups were compared with the chi-square χ2 test
or, Fisher’s exact test.
4) multivariable logistic regression model was undertaken comparing early versus late
anticoagulation for the outcome.
5) ORs are interpreted as risk ratios as the outcome was relatively rare.
result :
• The mRS, CHA2DS2VASC score and DOAC potential confounders, according to Bivariable
analysis.
• 90 days follow-up:
o 55 patients had at least one event within 90 days (event rate 4.1%). The median time to
ischemic stroke was 14 days (IQR 7–39) whereas the median time to ICH was 72 days (IQR
62–82).
o The event rate was 48/997 (5%) in the late-OAC group (two ICHs, 16 ischemic strokes (all
cardioembolic), 2 TIAs and 31 deaths ) versus;
o 7/358 (2%) in the early-OAC group (3 ischemic strokes (all cardioembolic), 2 TIAs and 2
deaths).
result :
Result :
Result :
Result :
1- How Serious Is the Risk of Bias?
2- aside From the exposure of Interest, Did the exposed and
Control groups start and Finish with the same risk for the
outcome?
3- were patients similar for prognostic Factors That are known
to
Be associated with the outcome
(or Did statistical adjustment Level address This Imbalance)?

4- Were the Circumstances and Methods for Detecting the
outcome similar?
5- was the Follow-up sufficiently Complete?

Thank you !!!
such a great group

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Early versus late anticoagulation for ischaemic

stroke associated with atrial fibrillation:

- To appraise papers critically

- Finally to have fun!!

statistical methods Result

They dichotomized according to their timing on starting OAC into :

The European Society UK guidelines for observational CT-

2- aside From the exposure of Interest, Did the exposed and

Be associated with the outcome

(or Did statistical adjustment Level address This Imbalance)?

5- was the Follow-up sufficiently Complete?

such a great group

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