Prognostic analysis of different therapeutic regimens in patients with acute cardiogenic cerebral embolism

Lan Hu,Yongjun Cao,Guangxin Duan,Yuan Xu

doi:10.1186/s12883-021-02348-9

Abstract

BackgroundFew studies focused on the functional outcomes of patients at 3 months after receiving intravenous thrombolysis, anticoagulation, or antiplatelet therapy within 4.5 h of onset of the cardiogenic cerebral embolism (CCE) subtype.MethodsThe purpose of this retrospective study was to analyse the clinical data of patients with acute CCE and compare the 3-month functional prognoses of patients after administration of different antithrombotic therapies within 4.5 h of stroke onset. A total of 335 patients with CCE hospitalized in our institution were included in this study. The patients were stratified according to the hyperacute treatment received, and baseline clinical and laboratory data were analysed. A 3-month modified Rankin scale (mRS) score of 0–2 was defined as an excellent functional outcome.ResultsA total of 335 patients were divided into thrombolytic (n = 78), anticoagulant (n = 88), and antiplatelet therapy groups (n = 169). A total of 164 patients had a good prognosis at 3 months (mRS ≤ 2). After adjustments were made for age and National Institute of Health Stroke Scale (NIHSS) score, each group comprised 38 patients, and there were no significant differences in sex composition, complications, lesion characteristics, or Oxfordshire Community Stroke Project (OSCP) classification among the three groups. The plasma D-dimer level (µg/ml) in the thrombolytic group was significantly higher than those in the anticoagulant and antiplatelet groups [3.07 (1.50,5.62), 1.33 (0.95,1.89), 1.61 (0.76,2.96), P < 0.001]. After one week of treatment, the reduction in NIHSS in the thrombolytic group was significantly greater than those in the other two groups [3.00 (1.00, 8.00), 1.00 (0.00, 5.00), 1.00 (0.00, 2.00), P = 0.025]. A total of 47 patients (41.2 %) had an mRS score of ≤ 2 at 3 months, and 23 patients died (20.2 %). There was no significant difference in the proportion of patients with a good prognosis or the mortality rate among the three groups (P = 0.363, P = 0.683).ConclusionsThrombolytic therapy is effective at improving short-term and 3-month prognoses. Anticoagulant therapy may be a safe and effective treatment option for patients with the cardiac stroke subtype who fail to receive intravenous recombinant tissue plasminogen activator (r-tPA) thrombolysis within 4.5 h in addition to antiplatelet therapy, as recommended by the guidelines.

Highlights

Few studies focused on the functional outcomes of patients at 3 months after receiving intravenous thrombolysis, anticoagulation, or antiplatelet therapy within 4.5 h of onset of the cardiogenic cerebral embolism (CCE) subtype
For patients whose onset times are within the treatment window, thrombolysis treatment, arterial embolectomy, and bridging therapy are recommended by the American Heart Association/American Stroke Association (AHA/ ASA) and European Society of Cardiology (ESC) guidelines [5, 6], and antiplatelet therapy is suggested during the hyperacute stage of CCE [5, 6]; the effectiveness of hyperacute anticoagulation remains controversial
Patients satisfying the following criteria were enrolled: (1) age > 18 years; (2) average time from onset to admission ≤ 4.5 h; (3) craniocerebral magnetic resonance imaging (MRI) or computed tomography (CT) performed to confirm a diagnosis of new cerebral infarction; (4) diagnostic criteria met for cardiogenic embolism according to Trial of Org 10,172 in the Acute Stroke Treatment (TOAST) classification [7]; and (5) heart disease defined as non-valvular atrial fibrillation (NVAF) with a history of atrial fibrillation of more than 1 month without medication or cardioversion, failure to undergo drug or electrical cardioversion, sinus rhythm that could not be maintained for an extended time, definite dilated heart disease, or rheumatic valvular heart disease

Summary

Introduction

Few studies focused on the functional outcomes of patients at 3 months after receiving intravenous thrombolysis, anticoagulation, or antiplatelet therapy within 4.5 h of onset of the cardiogenic cerebral embolism (CCE) subtype. The most common cause of CCE is non-valvular atrial fibrillation (NVAF) [2] Compared with those who have other ischaemic stroke subtypes, patients with CCE have more serious symptoms, poorer prognoses, higher mortality and a higher risk of recurrence or haemorrhagic conversion early after stroke onset [3, 4]. To provide a corresponding clinical reference for CCE subtypes, we retrospectively analysed the clinical characteristics of patients with CCE and compared their 3month clinical prognoses after receiving different antithrombotic drugs within 4.5 h of stroke onset using data from patients who did not receive either arterial embolectomy or bridging therapy but only drug treatment For patients whose onset times are within the treatment window, thrombolysis treatment, arterial embolectomy, and bridging therapy are recommended by the American Heart Association/American Stroke Association (AHA/ ASA) and European Society of Cardiology (ESC) guidelines [5, 6], and antiplatelet therapy is suggested during the hyperacute stage of CCE [5, 6]; the effectiveness of hyperacute anticoagulation remains controversial.

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