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. Nguyễn Huy Thắng


Why AF cause stroke ???


Anterior Cerebral Artery collaterals

Infarct Core

Ischemic
Penumbra
Posterior Cerebral
Artery collaterals


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

• 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%)

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


Mean Age 67,93 ± 28,44
n 236
Stroke Severity

23%
41%
36%

Mild Stroke

Moderate Stroke

Severe Stroke

4th Qt

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


Only ¼ of AF-Stroke pts can be independence !
0

45
40

1 2
40.3

3

4

5

6

33.8

35

mRS 3-5: 43.2%

22.8

30
25

22.5

20
13.6

15
10
5

16 16

12.3

1.7

5.1

4.2

1.4

5.6

4.7

0
Xuất viện
Discharge

3 tháng
90
days

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


Highest efficacy for stroke prevention in AF


Stroke Prevention Before Admission

Current Treatment
CHADs-VASc ≥ 1 : 97.9%

Case
(n = 236)

(%)

Anti-vitamin K

39

16.5

Antiplatelet

41

17.4

Combine anti-vitamin K and antiplatelet

2

0.8

Combine antiplatelet

4

1.7

150

63.6

No antithrombotic

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


N Engl J Med 2011;365:2002-12
Mar 2013


How are AF-Stroke patients often seen ?
Patient untreated
AIS

... on
anticoagulation

INR

AIS

ICH
AIS: acute ischemic stroke; ICH: intracranial hemorrhage

Anticoagulation in Stroke – Risks & Benefits
Neurologists ‘s Perspective

Stroke patients are always vulnerable
Increase of intracranial bleeding risk
Increase of recurrent stroke risk


Stroke and system embolism with Warfarin

International Journal of Cardiology 180 (2015) 246–254
13


Intracranial haemorrhage with Warfarin

International Journal of Cardiology 180 (2015) 246–254
14


Case 1

• BN nam 37 tuổi
• Rung nhĩ, cao huyết áp

• Đang được điều trị: aspirin, perindopril.
Nhập viện vì có nhiều cơn yếu ½ P, tự phục hồi
trong khoảng 60 phút.

Unremarkable brain CT Scan


Best Recipe for AF-Stroke patients

AF + STROKE or TIA

ANTICOAGULATION


When should we start Anticoagulation after IS ?
1 -3 -6 -12 rule of thumb
Severity of stroke
TIA

Day of administration after
stroke onset
As soon as possible

Small, non-disabling infarct

3

Moderate stroke

6

Large infarcts

12 (2 or 3 weeks)

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


How to start anticoagulation after TIA?

• Anti-vitamin K needs 3-5 days for achieve
therapeutic range.

• Bridging therapy with LMWH + Anti-vitamin K
may be a good choice.

• Noacs can get the maximal effect on
coagulation after few hours.


Case 2

• BN nam 67 tuổi
• Rung nhĩ, cao huyết ỏp

ã Nhp vin lỳc 7.30 sỏng, vỡ lit ẵ ngi T
sau khi ngủ dậy
• Thời gian bình thường gần nhất lúc 23g.


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
TIA

Day of administration after
stroke onset
As soon as possible

Small, non-disabling infarct

3

Moderate stroke

6

Large infarcts

12 (2 or 3 weeks)
Kirchhof P et al, Eur Heart J 2016; doi:10.1093/eurheartj/ehw210


What anticoagulation should use for?
• Anti-vitamin K needs 3-5 days for achieve
therapeutic range. So need to start at day 2-3

after repeated CT scan.

• How about Noacs ?


Look back of his Gradient echo MRI