Lege Artis Medicinae

[Antithrombotic therapy in cardiogenic thromboembolism]

LENGYEL Mária1

NOVEMBER 30, 1994

Lege Artis Medicinae - 1994;4(01 KLSZ)

[All 3 methods of antithrombotic therapy have a role in the primary and secondary prevention of cardiogenic thromboembolism. The most important modality is anticoagulant treatment which is indicated now in the majority of cases of nonvalvular atrial fibrillation. An tiplatelet therapy is of limited value in cardiogenic thromboembolism. The expanded clinical use of both kinds of treatment depends on increased safety and unchanged efficacy which can be achieved by reduced dosage and the combination of the two therapeutic methods. Thrombolytic therapy, until recently, has been limited to the thromboembolic diseases of the right heart. Presently, thrombolysis is being more and more often used in the lifesaving treatment of left sided prosthetic valve thrombosis. ]

AFFILIATIONS

  1. Országos Kardiológiai Intézet Budapest

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Further articles in this publication

Lege Artis Medicinae

[Introduction]

FENYVESI Tamás

[This LAM supplement was prompted by a very topical issue. Antithrombotic therapy has come to the forefront of the treatment of cardiovascular patients. Prolonged anticoagulant therapy involves mainly the use of coumarin derivatives, and platelet aggregation inhibition involves the extensive use of acetylsalicylic acid. The topicality of this issue can be approached from two angles. First, the incidence of ischaemic heart disease and cerebrovascular disease in the developed world is alarmingly high.]

Lege Artis Medicinae

[The role of echocardiography in anticoagulant treatment]

TEMESVÁRI András

[Echocardiography is the method of choice to detect the cardiac source of embolism. Trans thoracic echocardiography is preferred for the diagnosis of left ventricular thrombus. Trans esophageal echocardiography is more sensitive than transthoracic echocardiography in the detection of possible sources of systemic emboli (41-65% versus 14–37%). Left atrial and appendage thrombus, spontaneous echocontrast, patent foramen ovale, atrial septum aneurysm, left atrial myxoma and prosthetic valve thrombus are more frequently demonstrated by transeso phageal echocardiography. Right atilai and ventricular thrombus, embolus in the pulmonary artery, patent foramen ovale and pulmonary hypertension should be examined in pulmonary embolism. ]

Lege Artis Medicinae

[Anticoagulant treatment in cerebrovascular diseases]

NAGY Zoltán

[The practice and indication of anticoagulation in the care of cerebrovascular patients is still controversial. It is hoped that improved diagnostic facilities, the extensive use of imaging techniques, more accurate assessment and monitoring of haemostasis, and the increasing number of multicentre studies will help us to better define the conditions for treatment. The use of anticoagulant therapy may be justified in stroke prevention, mainly to prevent cardioembolisation in cases where the probability of stroke is higher than 5%, and in cerebral venous thrombosis and deep vein thrombosis. The use of anticoagulation in the treatment of progressive ischaemic stroke is still controversial. The experience with heparin (coumarins, warfarin) has been well established, whereas there is currently a lack of data and extensive clinical trials on the use of low molecular weight heparins, heparinoids. ]

Lege Artis Medicinae

[Coumarin therapy]

PÉTERFY Miklós

[Coumarin oral anticoagulants are highly effective antithrombotic agents with relatively low risks of serious bleeding. Clinical uses and applications have evolved over the years. Recent changes include a, lower doses are used to treat most patients with thromboses, b, laboratory monitoring has been standardised thus intensities of anticoagulation are equivalent around the world, C, new indications for treatment have emerged from prospoective controlled clinical trials, for example profilaxis of embolic stroke in patients with chronic nonrheumatic atrial fibrillation. Coumarins inhibit the factors II, VII, IX, X and protein C and S. Traditionally the prothrombin time has been used to monitor the antithrombotic effects of the coumarins. The test is performed by the addition of a thromboplastin to recalcified plasma. The sensitivity of the thromboplastin to coumarin induced reduction in clotting factor activity is variable in the assay. Some thromboplastins are very sensitive, others are insensitive. Consequently, patients can receive different doses of coumarin depending on the thromboplastin used. To address this important clinical problem, the prothrombin time ratio is now modified by a factor (ISI) that reflects the „sensitivity" of the thromboplastin used and the result is termed International Normalised Ratio (INR). The main coumarin adverse effects (hae morrhage, teratogenicity and coumarin skin necroses and some special problems of coumarin therapy (diet, coumarin resistance, drug-drug interactions, the problem of over lapping heparin and coumarin, the problem of interval surgery) are also discussed.]

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How does the use of antiplatelet and anticoagulants affect the success of mechanical thrombectomy in acute ischemic stroke cases?

ÇABALAR Murat , ŞENGEZE Nihat , EREN Alper , İNANÇ Yusuf , GİRAY Semih

In this study, we wanted to investigate the effect of antiplatelet and anticoagulant use on the success of mechanical thrombectomy in acute ischemic stroke cases. 174 patients who were brought to the Stroke Center of Gaziantep University Şahinbey Research and Practice Hospital between January 2018 and February 2019 due to acute ischemic stroke and who underwent mechanical thrombectomy were retrospectively analyzed. The demographic characteristics, antiplatelet/anticoagulant use before the stroke and mTICI (modified-Throm­bolysis-In-Cerebral-Infarction) scores used for reperfusion in mechanical thrombectomy were evaluated. The findings were analyzed statistically (p<0.05). The mean age was 63.3 ± 13.5 in 174 patients who underwent mechanical thrombectomy. 23/174 (13.2%) patients were using anticoagulant therapy (warfarin-OAC or new generation oral anticoagulant-NOAC) and 28/174 (16.1%) were using antiplatelet therapy. A history of atrial fibrillation (AF) was significantly higher in patients receiving anticoagulant therapy before acute ischemic stroke (p=0.001). Patients with a history of hyper tension (HT), diabetes mellitus (DM) and coronary artery disease (CAD) before acute ischemic stroke were receiving antiplatelet therapy in higher rates (respectively; p=0.003, p=0.037, p=0.005). Successful recanalization (mTICI ≥ 2b) was higher in patients with a history of anticoagulant use and who underwent mechanical thrombectomy (p=0.025). Our study showed that the use of anti­platelet or anticoagulants before mechanical thrombec­tomy may have an indirect positive effect on the success of the procedure.

Clinical Neuroscience

[The role of intravenous thrombolysis before mechanical thrombectomy in the treatment of large vessel occlusion strokes ]

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[The efficacy of intravenous thrombolysis (IVT) is moderate in the proximal vascular segments of intracranial arteries, as opposed to mecha­nical thrombectomy (MT). In the management of acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), IVT prior to MT is highly recommended based on the latest guidelines, but the necessity of IVT has been questioned by the latest studies of the past years. The aim of our study was to investigate and compare the efficacy and safety of direct mechanical thrombectomy (dMT) and combined therapy (CT) for patients who suffered an AIS with LVO and were treated in our department. We investigated patients with AIS caused by LVO who were admitted up to 4.5 hours after symptom onset and underwent MT in our department between November 2017 and August 2019. Patients’ data were collected in our stroke register. Patients enrolled in our study were divided into two groups depending on whether dMT or CT was used. Our primary outcome was the 30- and 90- day functional outcome measured by modified Rankin Scale (mRS). Mortality at 30- and 90- day, successful recanalization rates, and symptomatic intracranial hemorrhage were considered as secondary outcomes. A total of 142 patients (age: 68.3 ± 12.6 years, 53.5% female) were enrolled in our study, including 81 (57.0%) dMT cases, and 61 (43.0%) patients who received CT. The vascular risk factors and comorbidities were significantly higher in the dMT-treated group. At day 30, the rate of favorable functional outcomes was 34.7% in dMT vs. 43.6% among those who received CT (p = 0.307), by day 90 this ratio changed to 40.8% vs. 46.3% (p = 0.542). Mortality rates at day 30 were 22.2% and 23.6% (p = 0.851), and at day 90 33.8% and 25.9% (p = 0.343). The rate of effective recanalization was 94.2% for dMT-treated patients and 98.0% for CT-treated patients (p = 0.318). Symptomatic intracranial hemorrhage was detected in 2.5% of dMT-treated patients and 3.4% of CT-treated group (p = 0.757). Our results suggest that CT is associated with a moderately better outcome compared to dMT. IVT prior to MT did not increase the risk of symptomatic intracranial hemorrhages.]

Clinical Neuroscience

Is stroke indeed a “Monday morning disease”?

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Introduction - The therapeutic time window of acute stroke is short. Decision on the use of intravenous thrombolysis is based on well-defined criteria. Any delay in the transport to a designated stroke centre decreases the odds of therapeutic success. In Hungary, the admission rate of stroke patients peaks on Monday, the number gradually decreasing by the end of the week. This phenomenon has long been suggested to be due to the lack of emergency care approach. According to the literature, however, returning to work following a holiday is a risk factor for acute stroke. A similar phenomenon is well-known in veterinary medicine, a condition in horses referred to as ‘Monday morning disease’. In our study, we analysed the distribution of admissions due to acute stroke by the day of the week in 4 independent data sources. Patients and methods - The number of patients admitted to the Szent János Hospital, Budapest, Hungary with stroke and that of emergency ambulance transports in the whole city of Budapest due to acute stroke were analysed in the period between January 1 and March 31, 2009. The distribution of thrombolytic interventions reflecting hospitalizations for hyperacute stroke was analysed based on data of the Szent János Hospital in 2009-2012, and on national data from 2006-2012. Descriptive statistics was used to present the data. The variation between daily admission was compared by chi-square test. Results - The proportion of daily admission of stroke patients admitted to the Szent János Hospital was the highest at the beginning of the week (18% on Monday, and 21% on Tuesday) and the lowest on the weekend (9% and 9% on Saturday and Sunday, respectively). The distribution of ambulance transports in Budapest due to acute stroke tended to be similar (15% and 15% on Monday and Tuesday, whereas 13% and 12% on Saturday and Sunday, respectively) on different days of the week. No such Monday peak could be observed in a single centre regarding thrombolytic interventions: 18% and 19% of the total of 80 thrombolytic interventions in the Szent János Hospital were performed on Monday and Sunday, respectively. At the national level the higher Monday rate is obvious: during a 7-year period 16.0%, 12.7%, and 13.5% of all thrombolytic interventions in Hungary were performed on Monday, Saturday and Sunday, respectively. Conclusion - Monday preference of stroke is not exclusively caused by the lack of emergency care approach, and the phenomenon is not consistent at the individual hospital level in cases undergoing thrombolysis.

Clinical Neuroscience

[Clinical neurophysiological methods in diagnosis and treatment of cerebrovascular diseases]

NAGY Ildikó, FABÓ Dániel

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[Thrombolysis in case of ischemic stroke caused by aortic dissection]

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[Seldom, an acute aortic dissection can be the etiology of an acute ischemic stroke. The aortic dissection typically presents with severe chest pain, but in pain-free dissection, which ranges between 5-15% of the case, the neurological symptoms can obscure the sypmtos of the dissection. By the statistical data, there are 15-20 similar cases in Hungary in a year. In this study we present the case history of an acute ischemic stroke caused by aortic dissection, which is the first hungarian publication in this topic. A 59-year-old man was addmitted with right-gaze-deviation, acute left-sided weakness, left central facial palsy and dysarthric speech. An acute right side ischemic stroke was diagnosed by physical examination without syptoms of acute aortic dissection. Because, according to the protocol it was not contraindicated, a systemic intravenous thrombolysis was performed. The neurological sypmtoms disappeared and there were no complication or hypodensity on the brain computed tomography (CT). 36 hours after the thrombolysis, the patient become restlessness and hypoxic with back pain, without neurological abnormality. A chest CT was performed because of the suspition of the aortic dissection, and a Stanford-A type dissection was verified. After the acute aortic arch reconstruction the patient died, but there was no bleeding complication at the dissection site caused by the thrombolysis. This case report draws attention to the fact that aortic dissection can cause acute ischemic stroke. Although it is difficult to prove it retrospectively, we think the aortic dissection, without causing any symptoms or complain, had already been present before the stroke. In our opinion both the history of our patient and literature reviews confirms that in acute stroke the thrombolysis had no complication effect on the aortic dissection but ceased the neurological symptoms. If the dissection had been diagnosed before the thrombolysis, the aortic arch reconstruction would have been the first step of the treatment, without thrombolysis. ]