Objective

Risk of early recurrent ischemic stroke in patients with atrial fibrillation may be high. ASA/AHA guidelines provide imprecise recommendations on the timing and anticoagulant choice for this indication. We assessed current opinions of stroke neurologists.

Methods

Case scenarios describing patients with acute ischemic stroke (AIS) due to paroxysmal atrial fibrillation (AF) were presented to US board-certified stroke neurologists in an internet-based questionnaire. Questions assessed timing and choice of anticoagulation for secondary stroke prevention, factors prompting earlier anticoagulation, reasons for specific anticoagulant choice, and alternatives to anticoagulation in ineligible patients. Open-ended comments were also solicited.

Results

Responses were available from 238/1239 stroke neurologists surveyed. In patients with small AIS without hemorrhagic transformation (HT), 51% elected to start anticoagulation within 96 hours. With increased stroke severity and asymptomatic HT, only 29% and 26% respectively chose to anticoagulate within 7 days. Few requested stability imaging before starting anticoagulation. With symptomatic HT the majority (79%) waited >14 days. 93% would anticoagulate earlier if left atrium/left atrial appendage or acute left ventricular thrombi, or mechanical heart valve were present. Direct oral anticoagulants (DOACs) were the preferred anticoagulation strategy (64%), and the remaining 38% preferred Warfarin. Aspirin was preferred by 57% in anticoagulation ineligible.

Conclusion

Apart from AIS with symptomatic HT, there is a remarkable lack of consensus among stroke neurologists regarding the timing of anticoagulation for secondary stroke prevention in patients with AIS due to PAF. DOACs are the preferred anticoagulation strategy. More studies are required to clarify anticoagulant management in this patient population.

中文翻译：

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心房纤颤对卒中的抗凝选择和时机：对美国卒中专家的调查（ACT-SAFe）。

目的

房颤患者早期复发性缺血性卒中的风险可能很高。ASA / AHA指南针对该适应症的时间选择和抗凝剂选择提供了不准确的建议。我们评估了中风神经病学家的最新观点。

方法

在基于互联网的调查问卷中，向美国董事会认证的卒中神经病学家介绍了描述因阵发性房颤（AF）而导致急性缺血性卒中（AIS）患者的案例。这些问题评估了预防继发性卒中的抗凝时间和选择，促使早期抗凝的因素，特定抗凝选择的原因以及不合格患者抗凝的替代方法。还征集了不限成员名额的评论。

结果

可以从接受调查的238/1239名中风神经病学家那里获得答复。对于没有出血性转化（HT）的小AIS患者，有51％的患者选择在96小时内开始抗凝治疗。随着卒中严重程度和无症状HT的升高，分别只有29％和26％的患者在7天内选择了抗凝治疗。在开始抗凝之前很少有人要求进行稳定性成像。症状性HT的大多数（79％）等待时间超过14天。如果存在左心房/左心耳或急性左心室血栓或机械性心脏瓣膜，则93％的患者较早会抗凝。直接口服抗凝剂（DOAC）是首选的抗凝策略（64％），其余38％的首选华法林。阿司匹林因不适合抗凝治疗而被首选57％。

结论

除具有症状性HT的AIS外，卒中神经病学专家对因PAF引起的AIS继发性卒中的抗凝治疗时机还缺乏共识。DOAC是首选的抗凝策略。需要更多的研究来阐明该患者人群的抗凝治疗方法。