2 bài BS thắng tối ưu hóa dự phòng đột quỵ trên bệnh nhân rung nhi có tiền căn đột quỵ

SECONDARY STROKE PREVENTION IN NVAF PATIENTS WITH ANTICOAGULATION PGS.. Cao Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015 • Included 3561 IS patients admitt

SECONDARY STROKE PREVENTION IN

NVAF PATIENTS WITH ANTICOAGULATION

PGS Nguyễn Huy Thắng

Why AF cause stroke ???

Anterior Cerebral Artery collaterals

Posterior Cerebral Artery collaterals

Infarct Core

Ischemic

Penumbra

How severe of stroke are they ?

Stroke in Vietnames patients with atrial fibrillation

Prevalence and outcomes

Thang H Nguyen, Chi M.T.Do , Phong P Cao

Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015

• Included 3561 IS patients admitted to the People ‘ 115

hospital in the last 6 months of 2013.

• 236 pts was confirmed AF by ECG at the ER (6.63%)

Only ¼ of AF-Stroke pts can be independence !

Highest efficacy for stroke prevention in AF

Stroke Prevention Before Admission

Current Treatment

CHADs-VASc ≥ 1 : 97.9%

Case (n = 236) (%)

Mar 2013

N Engl J Med 2011;365:2002-12

How are AF-Stroke patients often seen ?

Anticoagulation in Stroke – Risks & Benefits

Neurologists ‘s Perspective

Stroke patients are always vulnerable

Increase of recurrent stroke risk

Increase of intracranial bleeding risk

Stroke and system embolism with Warfarin

International Journal of Cardiology 180 (2015) 246–254

Intracranial haemorrhage with Warfarin

International Journal of Cardiology 180 (2015) 246–254

• BN nam 37 tuổi

• Đang được điều trị: aspirin, perindopril

Nhập viện vì có nhiều cơn yếu ½ P, tự phục hồi

Case 1

Unremarkable brain CT Scan

AF + STROKE or TIA ANTICOAGULATION

Best Recipe for AF-Stroke patients

When should we start Anticoagulation after IS ?

1 -3 -6 -12 rule of thumb

Severity of stroke Day of administration after

stroke onset

Kirchhof P et al, Eur Heart J 2016; doi:10.1093/eurheartj/ehw210

• Anti-vitamin K needs 3-5 days for achieve

therapeutic range

may be a good choice

coagulation after few hours

How to start anticoagulation after TIA?

• BN nam 67 tuổi

Case 2

Wake-up stroke MRI protocol

Collateral Flow in Stroke patients

When should we start Anticoagulation

after IS ?

1 -3 -6 -12 rule of thumb

Severity of stroke Day of administration after

stroke onset

Moderate stroke 6

Kirchhof P et al, Eur Heart J 2016; doi:10.1093/eurheartj/ehw210

• Anti-vitamin K needs 3-5 days for achieve

therapeutic range So need to start at day 2-3 after repeated CT scan

What anticoagulation should use for?

Look back of his Gradient echo MRI

• We aimed to determine whether presence of cerebral

microbleeds can identify patients at high risk of

symptomatic intracranial haemorrhage when

anticoagulated for atrial fibrillation after recent ischaemic stroke or TIA.

• Study recruited 1490 pts from 79 hospitals in the UK and one in the Netherlands with AF and recent acute

ischaemic stroke or TIA, treated with a vitamin K

antagonist or direct oral anticoagulant, and followed up for 24 months.

Lancet Neurol 2018; 17: 539–47

Cerebral microbleeds were present in 311 (21%)

Lancet Neurol 2018; 17: 539–47

Symptomatic intracranial haemorrhage according to the presence or absence of cerebral microbleeds

Lancet Neurol 2018; 17: 539–47

Pts with CMB may be 5 times higher risk of sICH when using Anticoagulation !

Lancet Neurol 2018; 17: 539–47

sICH was most seen in VKA used !

Lancet Neurol 2018; 17: 539–47

AF Patients in ROCKET AF had Higher Risk of Stroke than Patients in Other Phase III Trials

CHADS 2 -Score patient distribution

1 Patel MR et al N Engl J Med 2011;365(10):883–891; 2 Connolly SJ et al N Engl J Med 2009;361(12):1139–1151;

3 Granger CB et al N Engl J Med 2011;365(11):981–992; 4 Edoxaban FDA Briefing Document page 158/398.

4 FDA Briefing Document page 158/398

CHADS 2 score

ROCKET AF có lượng BN có tiền căn đột quỵ và TIA nhiều

nhất so với các nghiên cứu pha III của NOACs

ROCKET AF 1–3 (n=14,264)

S 2 Prior stroke or TIA 52% 19% 28% 20%

Patients with AF in ROCKET AF had a higher risk of stroke than those in other

phase III trials with NOACs

1 Patel MR et al, N Engl J Med 2011;365:883–891; 2 Halperin JL et al, Circulation 2014;130:138–146; 3 Hankey GJ et al, Lancet Neurol 2012;315–322;

4 Granger CB et al, N Engl J Med 2011;365:981–992; 5 Easton JD et al, Lancet Neurol 2012:11:503–511; 6 Giugliano RP et al, N Engl J Med 2013;369:2093–2104;

7 Connolly SJ et al, N Engl J Med 2009;361:1139–1151; 8 Eikelboom JW et al, Circulation 2011;123:2363–2372

ROCKET AF: Stroke and ICH risk is always

higher in Prior Stroke Group

Prior stroke/TIA, warfarin

No prior stroke/TIA, Rivaroxaban

Prior stroke/TIA, Rivaroxaban

Months from randomisation 0

REAFFIRM: Nghiên cứu thế giới thực khẳng định lại an toàn và hiệu quả

của Rivaroxaban trên BN rung nhĩ có tiền căn đột quỵ/TIA

Favours rivaroxaban

*Ischaemic stroke/ICH

Coleman CI et al, Stroke 2017;48:2142–2149

When you have a AF-related stroke patient …

Conclusion

For secondary stroke prevention …

• Very effective for stroke prevention with

Anticoagulation.

• NOACs are superior or non-inferior compare with Anti Vitamin K.

• Brain micro-bleed is a new predictor for ICH among

AF patients NOACs are more safety to prevent ICH

in stroke prevention

What types of stroke do you likely to see?

-70%

-50%

Risk for Patients Risk for Doctors?