Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation.
Journal
Annals of neurology
ISSN: 1531-8249
Titre abrégé: Ann Neurol
Pays: United States
ID NLM: 7707449
Informations de publication
Date de publication:
07 2023
07 2023
Historique:
revised:
08
03
2023
received:
07
10
2022
accepted:
14
03
2023
medline:
30
6
2023
pubmed:
18
3
2023
entrez:
17
3
2023
Statut:
ppublish
Résumé
Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet). We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years). Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.
Substances chimiques
Fibrinolytic Agents
0
Anticoagulants
0
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
61-74Subventions
Organisme : Medical Research Council
ID : G1002605
Pays : United Kingdom
Organisme : Medical Research Council
ID : G108/613
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/J006971/1
Pays : United Kingdom
Organisme : Wellcome Trust
ID : WT088134/Z/09/A
Pays : United Kingdom
Informations de copyright
© 2023 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.
Références
Zeng J, Yu P, Cui W, et al. Comparison of HAS-BLED with other risk models for predicting the bleeding risk in anticoagulated patients with atrial fibrillation: a PRISMA-compliant article. Medicine 2020;99:e20782.
Friberg L, Rosenqvist M, Lip GYH. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish atrial fibrillation cohort study. Eur Heart J 2012;33:1500-1510.
Hilkens NA, Li L, Rothwell PM, et al. External validation of risk scores for major bleeding in a population-based cohort of transient ischemic attack and ischemic stroke patients. Stroke 2018;49:601-606.
Paciaroni M, Agnelli G, Falocci N, et al. Early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with non-vitamin-K oral anticoagulants (RAF-NOACs) study. J Am Heart Assoc 2017;6:1-13.
Fazekas F, Kleinert R, Roob G, et al. Histopathologic analysis of foci of signal loss on gradient-echo T2*- weighted MR images in patients with spontaneous intracerebral hemorrhage: evidence of microangiopathy-related microbleeds. Am J Neuroradiol 1999;20:637-642.
Koennecke H-C. Cerebral microbleeds on MRI: prevalence, associations, and potential clinical implications. Neurology 2006;66:165-171.
Rosand J, Eckman MH, Knudsen KA, et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med 2004;164:880-884.
Sun J, Soo YOY, Lam WWM, et al. Different distribution patterns of cerebral microbleeds in acute ischemic stroke patients with and without hypertension. Eur Neurol 2009;62:298-303.
Soo Y, Abrigo JM, Leung KT, et al. Risk of intracerebral haemorrhage in Chinese patients with atrial fibrillation on warfarin with cerebral microbleeds: the IPAAC-warfarin study. J Neurol Neurosurg Psychiatry 2019;90:428-435.
Wilson D, Ambler G, Shakeshaft C, et al. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study. Lancet Neurol 2018;17:539-547.
Charidimou A, Shams S, Romero JR, et al. Clinical significance of cerebral microbleeds on MRI: a comprehensive meta-analysis of risk of intracerebral hemorrhage, ischemic stroke, mortality, and dementia in cohort studies (v1). Int J Stroke 2018;13:454-468.
Kwa VIH, Algra A, Brundel M, et al. Microbleeds as a predictor of intracerebral haemorrhage and ischaemic stroke after a TIA or minor ischaemic stroke: a cohort study. BMJ Open 2013;3:e002575.
Best JG, Ambler G, Wilson D, et al. Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from coho. Lancet Neurol 2021;20:294-303.
Wilson D, Ambler G, Lee KJ, et al. Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2019;18:653-665.
Hald SM, Möller S, García Rodríguez LA, et al. Trends in incidence of intracerebral hemorrhage and association with antithrombotic drug use in Denmark, 2005-2018. JAMA Netw Open 2021;4:e218380.
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857-867.
Staals J, Makin SDJ, Doubal FN, et al. Stroke subtype, vascular risk factors, and total MRI brain small-vessel disease burden. Neurology 2014;83:1228-1234.
Seiffge DJ, Wilson D, Ambler G, et al. Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants. J Neurol Neurosurg Psychiatry 2021;92:805-814.
Pantoni L. Cerebral small vessel disease: from pathogenesis and clinical characteristics to therapeutic challenges. Lancet Neurol 2010;9:689-701.
Rosand J, Hylek EM, O'Donnell HC, Greenberg SM. Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study. Neurology 2000;55:947-951.
O'Donnell MJ, Eikelboom JW, Yusuf S, et al. Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study. Am Heart J 2016;178:145-150.
Shoamanesh A, Hart RG, Connolly SJ, et al. Microbleeds and the effect of anticoagulation in patients with embolic stroke of undetermined source: an exploratory analysis of the NAVIGATE ESUS randomized clinical trial. JAMA Neurol 2021;78:11-20.
Meya L, Polymeris A, Schaedelin S, et al. Oral anticoagulants in atrial fibrillation patients with recent stroke who are dependent on the daily help of others. Stroke 2021;52:3472-3481.
Polymeris AA, Macha K, Paciaroni M, et al. Oral anticoagulants in the oldest old with recent stroke and atrial fibrillation. Ann Neurol 2021;91:78-88.
Alqahtani F, Aljohani S, Tarabishy A, et al. Incidence and outcomes of myocardial infarction in patients admitted with acute ischemic stroke. Stroke 2017;48:2931-2938.
Lamberts M, Gislason GH, Lip GYH, et al. Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 2014;129:1577-1585.
Fox KAA, Velentgas P, Camm AJ, et al. Outcomes associated with Oral anticoagulants plus antiplatelets in patients with newly diagnosed atrial fibrillation. JAMA Netw Open 2020;3:e200107.
Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the Europea [internet]. Eur Heart J 2021;42:373-498. https://doi.org/10.1093/eurheartj/ehaa612.
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the Management of Patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the heart. J Am Coll Cardiol 2019;74:104-132.
Steffel J, Collins R, Antz M, et al. 2021 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Europace 2021;23:1612-1676.