DOACs and real world data: What have we learned that the RCTs have not told us? Acute Stroke George Ntaios University of Thessaly, Larissa
Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; CHUV; Belgian Stroke Council; Boehringer Ingelheim. Speaker fees: Sanofi; Boehringer Ingelheim; Galenica; Elpen; Bayer; Winmedica Support to attend conferences: Bayer; Sanofi Aventis; Pfizer; Lundbeck; Boehringer Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Participation in trials: NAVIGATE ESUS / Steering Committee member, National Coordinator (Greece) & Principal Investigator (Larissa) PRECIOUS / National Coordinator (Greece) & Executive Committee member. ENOS / National Coordinator (Greece). FOURIER / Principal investigator (Larissa). GLORIA AF / Sub investigator (Larissa). EBBINGHAUS / Principal Investigator (Larissa). BIOSIGNAL / Principal Investigator (Larissa). PREVISE / Principal investigator (Larissa). RECOVERY / Principal investigator (Larissa)
Ischemic stroke in anticoagulated patient
Ischemic stroke in anticoagulated patient Ηλικία <18 ή >80 >4.5 ώρες από την έναρξη του ΑΕΕ Άγνωστη ώρα έναρξης του ΑΕΕ NIHSS <4 ή >25 Ραγδαία κλινική βελτίωση Ενδοκράνιoς αιμορραγία (CT ή MRI) Υπόπυκνη περιοχή >30% της κατανομής της μέσης εγκεφαλικής Πρόσφατο ΑΕΕ (<3 μήνες) Ιστορικό ΑΕΕ και συνύπαρξη Σ Βαριά συννοσηρότητα Αιμορραγική διάθεση Βαριά ηπατοπάθεια Προηγούμενο αιμορραγικό ΑΕΕ Υποψία υπαραχνοειδούς αιμορραγίας ΑΠ >185/110 παρά τη χορήγηση IV ανθυπερτασικών Αιμοπετάλια <100,000/mm 3 Λήψη LMWH ή per os αντιπηκτικών (INR >1.5, aptt >33sec) Υποψία διαχωριστικού ανευρύσματος αορτής Ένδο ή περικαρδίτιδα, παγκρεατίτιδα Πρόσφατο (<3 μήνες) χειρουργείο/αιμορραγία πεπτικού ή ουροποιητικού Σάκχαρο <50 ή >400mg/dl Ενδοκράνιος όγκος ή ανεύρυσμα Επιληπτική κρίση κατά το ΑΕΕ Πρόσφατη (<10 ημ.) ανάνηψη/παρακέντηση αρτηρίας ή οσφυονωτιαία
Ischemic stroke in VKA anticoagulated patient
Ischemic stroke in VKA anticoagulated patient
Ischemic stroke in VKA anticoagulated patient
Ischemic stroke in VKA anticoagulated patient INR: 1.6
Ischemic stroke in VKA anticoagulated patient Λήψη LMWH ή per os αντιπηκτικών (INR >1.5, aptt >33sec)
Ischemic stroke in NOAC anticoagulated patient European Cardiology Review 2015;10:76 8
Idarucizumab: an antidote for dabigatran Thrombin Dabigatran Idarucizumab
Idarucizumab: an antidote for dabigatran
Idarucizumab: an antidote for dabigatran 70 65 60 dtt (s) 55 50 45 40 35 30 2 0 2 4 6 8 10 12 24 36 48 60 72 Time after end of infusion (hours)
Andexanet: : an antidote for Xa inhibitors Siegal et al. NEJM2015
Andexanet: : an antidote for Xa inhibitors
Andexanet: : an antidote for Xa inhibitors Siegal et al. NEJM2016
Ciraparantag: : an antidote for all Ansell et al. NEJM2014
Ciraparantag: : an antidote for all Ansell et al. NEJM2014
Ischemic stroke in NOAC anticoagulated patient
Acute endovascular treatment thrombectomy
Anticoagulation after AF stroke: how soon (or late?)
Anticoagulation after AF stroke: how soon (or late?) Ntaios & Michel. Cerebrovasc Dis 2011
Anticoagulation after AF stroke: how soon (or late?) Reasons to start early Reasons to wait Low NIHSS Small/no brain infarction on MRI High recurrence risk e.g. thrombus on echo No haemorrhagic transformation Patient is clinically stable Young patient Blood pressure is controlled High NIHSS Large/moderate brain infarction Haemorrhagic transformation Neurologically unstable Elderly patient Uncontrolled hypertension
The 1 3 6 121 12 rule TIA 1 day Small infarct 3 days Moderate infarct 6 days Large infarct 12 days
NOACs could be the answer? Ruff et al. Lancet 2013
Restart OAC after AF/OAC related ICH?
ESO ICH Guidelines Steiner et al. Int J Stroke. 2014
Restart OAC after AF/OAC related ICH Nielsen et al. Circulation 2015
Restart OAC after AF/OAC related ICH Nielsen et al. Circulation 2015
Restart OAC after AF/OAC related ICH Nielsen et al. Circulation 2015
Forget guidelines: we need to individualize
Bleeding vs. thromboembolic risk
Prognostic scores? Prognostic scores? HAS-BLED CHA2DS2-VASC2 CHADS2
Well, sorry.
Cerebral microbleeds
Cerebral microbleeds & ICH risk Charidimou et al. Stroke 2013
Cerebral microbleeds & ischemic stroke risk Charidimou et al. Stroke 2013
Forget guidelines: we need to individualize
NOAC vs. VKA: Intracranial haemorrhage Ruff et al. Lancet 2013
LAA occlusion? Holmes et al. JACC 2015
Talk & listen to your patients
Take home messages Stroke in anticoagulated patient? Restart antithrombotics after ICH? How soon OAC after IS?