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Recommendations for the use of new oral anticoagulants (NOACs) after TIA or stroke caused by atrial fibrillation (AF), after a consensus conference among Italian neurologists (the Venice group)

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Abstract

Vascular neurologists of Veneto and Friuli Venezia Giulia, north-east regions of Italy, have sought an agreement on the two following questions: (A) what prophylactic treatment should we recommend to patients with a stroke ascribed to atrial fibrillation (AF), who were not previously on antithrombotic treatment, to prevent further strokes? (B) What should we do in the event of an ischemic or hemorrhagic stroke associated with AF in patients who were already on antithrombotic treatment? There was a unanimous consensus for preferring the new oral anticoagulants (NOACs) in patients not taking any antithrombotics and in cases treated with antithrombotic drugs (coumadin and/or antiplatelets), due to a lower incidence of intracranial bleeding complications and a noninferiority for recurrent stroke or TIA. Even after intracranial bleeding complications, when it is useful or necessary to continue anticoagulant treatment, the group of experts preferred the NOACs, suggesting, however, to be very cautious in cases with widespread leukoaraiosis or microbleeds, practice frequent monitoring of creatinine clearance (CrCl) and avoid using NOACs when CrCl is <30 mL/min.

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References

  1. Janes F, Gigli GL, D’Anna L, Cancelli I, Perelli A, Canal G, Russo V, Zanchettin B, Valente M (2013) Stroke incidence and 30-day and six-month case fatality rates in Udine, Italy: a population-based prospective study. Int J Stroke. doi:10.1111/ijs.12000

    PubMed  Google Scholar 

  2. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C, Morillo CA, Carlson M, Themeles E, Kaufman ES, Hohnloser SH, for the ASSERT Investigators (2012) Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 366:120–129

    Article  CAS  PubMed  Google Scholar 

  3. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L, RE-LY Steering Committee and Investigators (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151

    Article  CAS  PubMed  Google Scholar 

  4. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM, ROCKET AF Investigators (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365(10):883–891

    Article  CAS  PubMed  Google Scholar 

  5. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365(11):981–992

    Article  CAS  PubMed  Google Scholar 

  6. Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, Flaker G, Avezum A, Hohnloser SH, Diaz R, Talajic M, Zhu J, Pais P, Budaj A, Parkhomenko A, Jansky P, Commerford P, Tan RS, Sim KH, Lewis BS, Van Mieghem W, Lip GY, Kim JH, Lanas-Zanetti F, Gonzalez-Hermosillo A, Dans AL, Munawar M, O’Donnell M, Lawrence J, Lewis G, Afzal R, Yusuf S, AVERROES Steering Committee and Investigators (2011) Apixaban in patients with atrial fibrillation. N Engl J Med 363(9):806–817

    Article  Google Scholar 

  7. Connolly SJ, Wallentin L, Ezekowitz MD, Eikelboom J, Oldgren J, Reilly PA, Brueckmann M, Pogue J, Alings M, Amerena JV, Avezum A, Baumgartner I, Budaj AJ, Chen JH, Dans AL, Darius H, Di Pasquale G, Ferreira J, Flaker GC, Flather MD, Franzosi MG, Golitsyn SP, Halon DA, Heidbuchel H, Hohnloser SH, Huber K, Jansky P, Kamensky G, Keltai M, Kim SS, Lau CP, Le Heuzey JY, Lewis BS, Liu L, Nanas J, Omar R, Pais P, Pedersen KE, Piegas LS, Raev D, Smith PJ, Talajic M, Tan RS, Tanomsup S, Toivonen L, Vinereanu D, Xavier D, Zhu J, Wang SQ, Duffy CO, Themeles E, Yusuf S (2013) The long-term multicenter observational study of dabigatran treatment in patients with atrial fibrillation (RELY-ABLE) study. Circulation 128(3):237–243

    Article  CAS  PubMed  Google Scholar 

  8. Hankey GJ, Patel MR, Stevens SR, Becker RC, Breithardt G, Carolei A, Diener HC, Donnan GA, Halperin JL, Mahaffey KW, Mas JL, Massaro A, Norrving B, Nessel CC, Paolini JF, Roine RO, Singer DE, Wong L, Califf RM, Fox KA, Hacke W et al (2012) Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF. Lancet Neurol 11:315–322

    Article  CAS  PubMed  Google Scholar 

  9. Diener HC, Connolly SJ, Ezekowitz MD, Wallentin L, Reilly PA, Yang S, Xavier D, Di Pasquale G, Yusuf S, RE-LY Study Group (2010) Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol 9:1157–1163

    Article  CAS  PubMed  Google Scholar 

  10. Easton JD, Lopes RD, Bahit MC, Wojdyla DM, Granger CB, Wallentin L, Alings M, Goto S, Lewis BS, Rosenqvist M, Hanna M, Mohan Alexander JH, Diener HC, ARISTOTLE Committees and Investigators (2012) Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol 11(6):503–511. doi:10.1016/S1474-4422(12)70092-3 (Epub 2012 May 8. Erratum in: Lancet Neurol. 2012 Dec; 11(12):1021)

    Article  CAS  PubMed  Google Scholar 

  11. Rasmussen LH, Larsen TB, Graungaard T, Skjoth F, Lip G (2012) Primary and secondary prevention with new oral anticoagulant drugs for stroke prevention in atrial fibrillation: indirect comparison analysis. BMJ 5(345):e7097. doi:10.1136/bmj.e7097

    Article  Google Scholar 

  12. Olesen JB, Lip GY, Lindhardsen J, Lane DA, Ahlehoff O, Hansen ML, Raunsø J, Tolstrup JS, Hansen PR, Gislason GH, Torp-Pedersen C (2011) Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a “real word” nationwide cohort study. Thromb Haemost 106(4):739–749

    Article  CAS  PubMed  Google Scholar 

  13. Connolly SJ, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, Pfeffer M, Hohnloser S, Yusuf S, ACTIVE writing group of the ACTIVE investigators (2006) 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 367(9526):1903–1912

    Article  CAS  PubMed  Google Scholar 

  14. Olesen JB, Lip GY, Kamper AL, Hommel K, Køber L, Lane DA, Lindhardsen J, Gislason GH, Torp-Pedersen C (2012) Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med 367(7):625–635

    Article  CAS  PubMed  Google Scholar 

  15. Ware K, Brodsky P, Satoskar AA, Nadasdy T, Nadasdy G, Wu H, Rovin BH, Bhatt U, Von Visger J, Hebert LA, Brodsky SV (2011) Warfarin-related nephropathy modeled by nephron reduction and excessive anticoagulation. J Am Soc Nephrol 22(10):1856–1862

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  16. Lip GY (2011) The role of aspirin for stroke prevention in atrial fibrillation. Nat Rev Cardiol 8(10):602–606

    Article  CAS  PubMed  Google Scholar 

  17. Wallentin L, Yusuf S, Ezekowitz MD, Alings M, Flather M, Franzosi MG, Pais P, Dans A, Eikelboom J, Oldgren J, Pogue J, Reilly PA, Yang S, Connolly SJ, RE-LY investigators (2010) Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet 376(9745):975–983

    Article  CAS  PubMed  Google Scholar 

  18. Charidimou A, Krishnan A, Werring DJ, Jager R (2013) Cerebral microbleeds: a guide to detection and clinical relevance in different disease setting. Neuroradiology 55(6):655–674

    Article  PubMed  Google Scholar 

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Acknowledgments

Experts who took part in the meeting and in the drafting of the document: Toso Vito (The Italian Stroke Forum), Baracchini Claudio (SU, Padova), Bovi Paolo (SU, Verona), Bruno Sandro (SU, Conegliano Veneto), Burlina Alessandro (SU, Bassano del Grappa) Calò Lorenzo (Internal Medicine Padova-University), Caneve Giorgio (SU, Feltre) Carletti Monica (SU, Verona), D’Anna Sebastiano (SU, Portogruaro), Fattorello Salimbeni Carlo (SU, Mirano), Gentile Manrico (SU, Belluno), Gigli Gian Luigi (SU, Udine-University), Giometto Bruno (SU, Treviso), Guzzon Sandro (SU, Monselice), Lazzarino De Lorenzo Lucio (Neurology Gorizia), L’Erario Roberto (SU, Rovigo), Maccarrone Giuseppe (SU, Castelfranco Veneto), Meneghetti Giorgio (Neurology Padova-University), Michieli Giorgio (SU, Piove di Sacco), Morra Michele (SU, Arzignano), Paladin Francesco (SU, Venezia), Perini Francesco (SU, Vicenza), Polo Alberto (SU, Legnago), Quatrale Rocco (SU, Mestre), Rana Michele (SU, Udine), Rigo Fausto (Cardiology Mestre), Sanson Flavio (SU Thiene), Stritoni Paolo (Cardiologist Treviso), Turinese Emanuele (SU, Bassano del Grappa), Valente Mariarosaria (SU, Udine-University), Vescovo Giorgio (Medical Department Vicenza). The following neurologists were unable to take part in the Consensus Conference, but wish to endorse this document and have undersigned it: Eleopra Roberto (SU, Udine), Pizzolato Gilberto (SU, Trieste-University).

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    Vito Toso

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Correspondence to Vito Toso.

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Membership is: The Italian Stroke Forum © 2012 via A. Cesalpino 5/b Florence.

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Toso, V. Recommendations for the use of new oral anticoagulants (NOACs) after TIA or stroke caused by atrial fibrillation (AF), after a consensus conference among Italian neurologists (the Venice group). Neurol Sci 35, 723–727 (2014). https://doi.org/10.1007/s10072-013-1590-7

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  • DOI: https://doi.org/10.1007/s10072-013-1590-7

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