The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian
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The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian cohort and a proposed algorithm E. Rota1 · L. Testa1 · G. Di Brigida1 · S. Agosti2 · M. E. Rovere2 · R. Risso3 · N. Morelli4
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Approximately 1–2% of patients with non-valvular atrial fibrillation have an acute ischemic stroke (AIS) while on direct oral anticoagulant (DOAC) treatment every year. However, current evidence on stroke subtypes, pathophysiology and factors leading to the failure of DOAC preventive therapy in a “real world” setting is still scanty. This study aimed at investigating whether there is any relationship between DOAC plasma levels and the stroke occurrence, on the basis of the phenotypic classification and pathophysiology of the stroke, in a cohort of DOAC-treated patients admitted to our hospital for AIS over 1-year period. A total of 28 patients had DOAC plasma levels determined in emergency and were included in the study, nine patients receiving dabigatran, 11 rivaroxaban and 8 apixaban. The DOAC levels were low in 8/28 patients (28.6% of the sample), intermediate in 4 (14.3%) and high in 16 (57.1%). The most prevalent stroke subtype was the small vessel disease, according to the A-S-C-O phenotypic classification, in 53.6% of our sample. The most common clinical presentation was “minor stroke” in 71.4% of the cases. There was a significantly higher proportion of patients with high DOAC levels in the small vessel group, compared to the cardioembolic group without other phenotypes. The question arises as to the most suitable clinical management of AIS in these patients on DOACs. In the current absence of clear evidence, taking into account the DOAC levels (low/intermediate/high) and the underlying stroke pathophysiology, we present a flowchart of our proposed clinical management of ischemic stroke in patients while on DOAC. Keywords Direct oral anticoagulants (DOACs) · Dabigatran · Rivaroxaban · Apixaban · DOAC levels · Clinical management
Highlights • The management of patients with an acute ischemic
stroke (AIS) while on DOAC treatment is challenging for clinicians.
* E. Rota [email protected] 1
Neurology Department, ASL Alessandria (AL), Via E. Raggio 12, 15067 Novi Ligure, AL, Italy
2
Cardiology Unit, San Giacomo Hospital, Novi Ligure, AL, Italy
3
Internal Medicine Unit, Santo Spirito Hospital, ASL CN2, Bra, CN, Italy
4
Neurology and Radiology Unit, Guglielmo da Saliceto Hospital, AUSLPC, Piacenza, PC, Italy
• Although DOACs require no routine coagulation moni-
toring in current clinical practice, there is increasing data that suggest a correlation between low DOAC levels and thrombotic complications. • This study makes a retrospective assessment of DOAC plasma levels, clinical features and the pathophysiological subtype of stroke in the DOAC-treated patients admitted to our hospital for AIS over a one-year period. • The main findings are that: (1) DOAC plasma level
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