心房颤动患者急性缺血性卒中后口服抗凝的起始时间

M. Smythe, D. Parker, Candice L. Garwood, A. Cuker, S. Messé
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引用次数: 14

摘要

急性缺血性卒中心房颤动(AF)患者在急性卒中后有出血转化和复发性缺血性卒中的风险。口服抗凝药物被推荐用于房颤患者的二级卒中预防。房颤患者急性缺血性卒中后开始抗凝治疗的最佳时间尚不确定。人们担心早期开始会增加出血性转化的风险,而延迟开始则会使患者处于复发性缺血性卒中的风险中。在本文中,我们回顾了急性缺血性卒中出血转化的风险,并回顾了AF患者急性缺血性卒中后抗凝起始时间的文献和主要指南。从1990年至今发表的相关文章通过PubMed和Embase数据库进行了识别。大多数可用的文献都是观测数据。大的缺血性病变、脑微出血、溶栓治疗和其他临床因素可能增加急性缺血性脑卒中出血转化的风险。48小时内静脉抗凝与出血转化的风险增加有关,不建议使用。目前还没有足够的数据支持急性缺血性卒中后48小时内常规口服抗凝剂(直接口服抗凝剂或华法林)的安全性。急性缺血性中风后2天内直接口服抗凝剂可使出血转化率降低5%。梗死面积和出血的存在是确定最佳起始时间的重要因素,并应在可行的情况下指导决策。为患者决策提供了一个推荐的框架。需要在这一领域进行随机对照试验,以确定抗凝起始的最佳时机,此类试验正在进行中。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation
Patients with atrial fibrillation (AF) who suffer an acute ischemic stroke are at risk for both hemorrhagic transformation and recurrent ischemic stroke in the acute post‐stroke period. Oral anticoagulants are recommended for secondary stroke prevention in patients with AF. The optimal time to initiate anticoagulant therapy after acute ischemic stroke in patients with AF is uncertain. There is concern that early initiation increases the risk of hemorrhagic transformation, whereas delayed initiation leaves the patient at risk for recurrent ischemic stroke. In this article, we provide a review of the risk of hemorrhagic transformation of acute ischemic stroke as well as review the literature and major guidelines addressing the timing of anticoagulation initiation after an acute ischemic stroke in patients with AF. Relevant articles published from 1990 to the present were identified using the PubMed and Embase databases. The majority of available literature is observational data. Large ischemic lesions, cerebral microbleeds, thrombolytic therapy, and other clinical factors may increase the risk of hemorrhagic transformation of an acute ischemic stroke. Parenteral anticoagulation within 48 hours is associated with an increased risk of hemorrhagic transformation and is not recommended. Insufficient data exist to support the safety of routine oral anticoagulant (direct oral anticoagulants or warfarin) initiation within 48 hours of an acute ischemic stroke. Direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation. Infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation and should guide decisions when available. A recommended framework for patient decision making is provided. Randomized controlled trials in this area are needed to identify the optimal timing of anticoagulation initiation, and such trials are under way.
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