Highlights
- •The first study to assess factors that determine bleeding acceptance in stroke survivors.
- •Type of secondary stroke prevention affects bleeding acceptance.
- •Anticoagulation in AF patients after stroke is associated with low bleeding acceptance.
- •Revascularization in acute stroke lowers bleeding acceptance in stroke survivors.
Abstract
Objectives
Prior ischemic cerebrovascular event and younger age have been shown to increase bleeding
acceptance among anticoagulated outpatients with atrial fibrillation (AF). We sought
to determine factors affecting bleeding acceptance in acute ischemic stroke (AIS)
survivors on various types of antithrombotic therapy.
Materials and Methods
We enrolled 173 consecutive patients hospitalized for AIS (aged 68.2±11.7 years, 54.9%
male), including 54 (31.2%) with AF, who had favorable functional outcome. On discharge,
the Bleeding ratio, defined as the declared maximum number of major bleedings that
a patient is willing to accept to prevent one major stroke, was evaluated. We assessed
the predicted bleeding risk in non-cardioembolic and cardioembolic stroke survivors
using S2TOP-BLEED and HAS-BLED scores, respectively.
Results
Patients with the low Bleeding ratio, defined as 5 (median) or less accepted bleeds
(n=92; 53.2%), were older and more likely to receive thrombolysis and/or thrombectomy,
with no impact of previous stroke. Prior major bleed (odds ratio [OR] 4.67; 95% confidence
interval [CI] 0.92-23.72), AF with use of oral anticoagulants (OR 2.35, 95% CI 1.12-4.93),
reperfusion treatment (OR 1.95, 95% CI 1.02-3.76), and hospitalization ≤10 days (OR
4.56; 95% CI 1.50-13.87) were associated with the low Bleeding Ratio. Prior use of
anticoagulants or aspirin as well as HAS-BLED and S2TOP-BLEED scores did not affect the bleeding acceptance.
Conclusions
Lower bleeding acceptance declared on discharge by AIS survivors is determined by
prior bleeding, anticoagulation in AF, reperfusion treatment, and duration of hospitalization,
which might affect medication adherence. The results might help optimize post-discharge
management and educational efforts in patients on antithrombotic therapy.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Stroke and Cerebrovascular DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Neurol. 2021; 20: 795-820
- 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association [published correction appears in Stroke.Stroke. 2021; 52 (. 2021 Jul;52(7):e483-e484]): e364-e467
- The Acute STroke Registry and Analysis of Lausanne (ASTRAL): design and baseline analysis of an ischemic stroke registry including acute multimodal imaging.Stroke. 2010; 41: 2491-2498
- An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Aug;50(8):e239].Stroke. 2013; 44: 2064-2089
- Effect of clopidogrel with aspirin on functional outcome in TIA or minor stroke: CHANCE substudy.Neurology. 2015; 85: 573-579
- Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis.Circulation. 2013; 128: 1656-1666
- Heart disease and stroke statistics—2020 update: a report from the American Heart Association external icon.Circulation. 2020; 141: e139-e596
- Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group.Lancet. 1993; 342: 1255-1262
- Major Bleeding Rates in Atrial Fibrillation Patients on Single, Dual, or Triple Antithrombotic Therapy.Circulation. 2019; 139: 775-786https://doi.org/10.1161/CIRCULATIONAHA.118.036248
- Efficacy and Safety of Using Dual Versus Monotherapy Antiplatelet Agents in Secondary Stroke Prevention: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials.Circulation. 2021; 143: 2441-2453
- Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.Lancet. 2006; 367: 1903-1912
- Direct oral anticoagulants versus warfarin in patients with atrial fibrillation: patient-level network meta-analyses of randomized clinical trials with interaction testing by age and sex.Circulation. 2022; 145: 242-255
- Oral anticoagulant therapy in atrial fibrillation patients at high stroke and bleeding risk.Prog Cardiovasc Dis. 2015; 58: 177-194
- Evaluation of patients’ attitudes towards stroke prevention and bleeding risk in atrial fibrillation.Thromb Haemost. 2014; 111: 465-473
- Bleeding tolerance among patients with atrial fibrillation on oral anticoagulation.Can J Cardiol. 2020; 36: 500-508https://doi.org/10.1016/j.cjca.2019.09.004
- Patients' perceptions of atrial fibrillation, stroke risk, and oral anticoagulation treatment: an international survey.TH Open. 2018; 2: e233-e241
- What should be defined as good outcome in stroke trials; a modified Rankin score of 0-1 or 0-2?.J Neurol. 2008; 255: 867-874
- European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke [published online ahead of print, 2019 Feb 26].J Neurointerv Surg. 2019; (neurintsurg-2018-014569)
- European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke.Eur Stroke J. 2021; 6: I-LXII
- Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Dec;50(12):e440-e441].Stroke. 2019; 50: e344-e418
- 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.Eur Heart J. 2021; 42 ([published correction appears in Eur Heart J. 2021 Feb 1;42(5):507] [published correction appears in Eur Heart J. 2021 Feb 1;42(5):546-547] [published correction appears in Eur Heart J. 2021 Oct 21;42(40):4194]): 373-498
National Institute for Health and Care Excellence. Stroke rehabilitation in adults Clinical guideline [CG162] Published: 12 June 2013 https://www.nice.org.uk/guidance/cg162/evidence Accessed: 08 February 2022.
- Predicting major bleeding in patients with noncardioembolic stroke on antiplatelets: S2TOP-BLEED.Neurology. 2017; 89: 936-943
- A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.Chest. 2010; 138: 1093-1100
- A clinical decision aid for the selection of antithrombotic therapy for the prevention of stroke due to atrial fibrillation.Eur Heart J. 2012; 33: 2163-2171
- Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study.BMJ Open. 2017; 7e018242
- The modified National Institutes of Health Stroke Scale: its time has come.Int J Stroke. 2009; 4: 267-273
- Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo.Stroke. 2020; 51: 1226-1230
- Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment.Stroke. 1993; 24: 35-41
- Interobserver agreement for the assessment of handicap in stroke patients.Stroke. 1988; 19: 604-607
- Direct oral anticoagulants in patients with atrial fibrillation following bariatric surgery: A single center experience.Kardiol Pol. 2021; 79: 1378-1381
- Dietary habits, lifestyle factors and neurodegenerative diseases.Neural Regen Res. 2020; 15: 394-400https://doi.org/10.4103/1673-5374.266045
- Acceptance of a potential major bleeding among patients with venous thromboembolism on long-term oral anticoagulation: the knowledge of the disease and therapy matters.Thromb Res. 2020; 193: 116-121https://doi.org/10.1016/j.thromres.2020.05.037
- Long-term adherence to direct acting oral anticoagulants and the influence of health beliefs after switching from vitamin-K antagonists: Findings from the Switching Study.Thromb Res. 2021; 208: 162-169https://doi.org/10.1016/j.thromres.2021.11.003
- Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly.Neurology. 2005; 65 ([published correction appears in Neurology. 2006 Feb 28;66(4):493]): 835-842
- Influence of Direct Oral Anticoagulants on Rates of Oral Anticoagulation for Atrial Fibrillation.J Am Coll Cardiol. 2017; 69: 2475-2484
- Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review.Patient. 2017; 10: 17-37
- Trends in antithrombotic management of patients with atrial fibrillation. A report from the Polish part of the EURObservational Research Programme - Atrial Fibrillation General Long-Term Registry.Pol Arch Intern Med. 2020; 130: 196-205
- Cardiology CathLab-based multispecialty stroke thrombectomy - Poland is moving on!.Kardiol Pol. 2021; 79: 612-613https://doi.org/10.33963/KP.a2021.0032
- Bleeding risk assessment for stroke patients on antithrombotic therapy. Evaluación del riesgo hemorrágico de la terapia antitrombótica en pacientes con ictus.Clin Investig Arterioscler. 2019; 31: 282-288https://doi.org/10.1016/j.arteri.2019.01.006
- How can the results of the COMPASS trial benefit patients with coronary or peripheral artery disease in Poland?.Kardiol Pol. 2019; 77: 661-669https://doi.org/10.33963/KP.14855
- Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study.J Am Heart Assoc. 2021; 10e019979
- Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study.J Geriatr Cardiol. 2020; 17: 502-509
- Differences in acute ischemic stroke care in Poland: analysis of claims database of National Health Fund in 2017.Neurol Neurochir Pol. 2020; 54: 449-455
- The utility of health states after stroke: a systematic review of the literature.Stroke. 2001; 32: 1425-1429
Article info
Publication history
Published online: November 16, 2022
Accepted:
November 11,
2022
Received in revised form:
November 7,
2022
Received:
August 4,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106894
Copyright
© 2022 Elsevier Inc. All rights reserved.
