Stones, lithotripters, trails, and arguments

Abstract

<h3>Background</h3> The National Authority for Health (HAS) updated in 2018 its recommendations on the anticoagulation for vascular prevention after ischaemic stroke. <h3>Purpose</h3> The objective was to assess and compare oral anticoagulant (OAC) prescriptions to the guidelines in patients hospitalised for ischaemic stroke in a stroke unit. <h3>Material and methods</h3> This was an observational retrospective study of OACs prescriptions including Vitamin K antagonist (VKA) and direct-acting oral anticoagulant (DOAC) in patients admitted for ischaemic stroke in a comprehensive stroke centre. Data on prescribed OAC from January to August 2018 was collected from the electronic inpatient records. The prescriptions’ evaluation was based on indication, dosage and drug interactions for DOAC, and indication and bridging anticoagulation for VKA. The thrombotic risk was quantified using the CHA2DS2-VASC score. <h3>Results</h3> The mean age of the 86 included patients was 72.8±14.5 years old (49% female). About 69% had an OAC initiation during hospitalisation and 31% was previously treated. At hospitalisation discharge DOAC were three times more prescribed than VKA (77% versus 23%). DOAC prescriptions of 92% conformed to the guidelines (dosage and no drug interaction). VKA prescriptions could not be evaluated because of ambulatory follow-up. The main OAC therapeutic indication was a confirmed atrial fibrillation (AF) in 62% patients (mean CHA2DS2-VASC=4.93±1.36). In 21%, AF was suspected, based on an association of factors such as: atrial hyperexcitability (59%), dilated left atrium (47%) and ischaemic stroke background in patients undergoing antiplatelet therapy (23%) (mean theoretical CHA2DS2-VASC=4.82±1.67). The remaining indications for OAC were: patent foramen ovale (PFO) before closure (7%, only DOAC), mechanical heart valve (5%, only VKA) and antiphospholipid syndrome (APS) (2%, only VKA). <h3>Conclusion</h3> Even though HAS gave no recommendation concerning OAC prescription in patients with an AF suspicion, neurologists prescribe it to prevent relapse stroke risk due to paroxysmal AF. A Holter monitoring is prescribed after discharge to decide upon the continuation of OAC at the neurologist’s follow-up visit. This practice should be investigated further to prove its efficiency. Concerning mechanical heart valves, neurologists follow the HAS recommendations. For PFO, neurologists use DOAC regardless of the HAS recommendations. No recommendation has been given for APS. <h3>References and/or acknowledgements</h3> https://www.has-sante.fr/portail/jcms/c_1252051/fr/prevention-vasculaire-apres-un-infarctus-cerebral-ou-un-accident-ischemique-transitoire No conflict of interest.