Stroke in the era of NOACs
George Ntaios MD, MSc (Stroke Medicine), PhD
University of Thessaly, Greece
Oslo11/12/2015
Disclosures
Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim.Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Elpen; BayerSupport to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; BMS Participation in trials:
– NAVIGATE-ESUS / National Coordinator (Greece)– GLORIA-AF / Sub-investigator (Larissa).– FOURIER / Principal investigator (Larissa).– PRECIOUS / National Coordinator (Greece).– ENOS / National Coordinator (Greece).– EBBINGHAUS / Principal Investigator (Larissa).– BIOSIGNAL / Principal Investigator (Larissa).– PREVISE / Principal investigator (Larissa).
Hercules and Lernaean Hydraby Lorenzo Matialli, Habsburg Palace, Vienna
Anticoagulation after AF-stroke: how soon (or late?)
Anticoagulation after AF-stroke: how soon (or late?)
Anticoagulation after AF-stroke: how soon (or late?)
Reasons to start early
• Low NIHSS • Small/no brain infarction on MRI• High recurrence risk e.g. thrombus on
echo• No haemorrhagic transformation• Patient is clinically stable• Young patient• Blood pressure is controlled
Reasons to wait
• High NIHSS • Large/moderate brain infarction• Haemorrhagic transformation• Neurologically unstable• Elderly patient• Uncontrolled hypertension
The 1-3-6-12 rule
TIA 1 day
Small infarct 3 days
Moderate infarct 6 days
Large infarct 12 days
NOACs could be the answer?
Ntaios et al. Stroke 2012
Intracranial haemorrhage while on anticoagulants
ESO ICH Guidelines
Steiner et al. Int J Stroke. 2014
Ntaios et al. Int J Stroke. 2015;Suppl A100:128-35
ESO ICH Guidelines
Steiner et al. Int J Stroke. 2014
NOACs could be the answer?
Ntaios et al. Stroke 2012
Ntaios & Lip. Curr Opin Neurol 2015
Our patient (… and his grand-grand-son)
81yrs
Fully independent at 3months
Hypertensive, Non-smoker, non-diabetic
LDL: 104mg/dl
LA diameter: 42mm
Triplex: -
24hrs ECG: -
Hart et al. Lancet Neurol 2014; 13: 429–38
ESUS: Embolic Strokes of Undetermined Source
ESUS: diagnostic criteria
Stroke detected by CT or MRI that is not lacunar.
Absence of extracranial or intracranial atherosclerosis causing >50% luminal stenosis in arteries supplying the area of ischemia.
No major-risk cardioembolic source of embolism (permanent or paroxysmal AF, sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, atrial myxoma or other cardiac tumours, mitral stenosis, recent (<4 weeks) MI, LVEF<30%, valvular vegetations, or infective endocarditis).
No other specific cause of stroke identified.
Hart et al. Lancet Neurol 2014; 13: 429–38
ESUS: potential causes
Hart et al. Lancet Neurol 2014; 13: 429–38
Hart et al. Lancet Neurol 2014; 13: 429–38
ESUS: Embolic Strokes of Undetermined Source
ESUS in the Athens Stroke Registry
Ntaios et al. Stroke 2015; 46:176-81
ESUS: stroke severity
Ntaios et al. Stroke 2015; 46:176-81
ESUS: 5-yrs functional outcome
Ntaios et al. Stroke 2015; 46:2087-93
ESUS: 5-yrs stroke recurrence
Ntaios et al. Stroke 2015; 46:2087-93
So, how to treat my ESUS patient?
Furie et al. Stroke 2011;42:227-76
Approach 1
So, how to treat my ESUS patient?
Approach 2
So, how to treat my ESUS patient?
Approach 3
RESPECT - ESUS
Dabigatran 110/150 1x2
Aspirin 100mg 1x1R
NAVIGATE - ESUS
Rivaroxaban 15mg 1x1
Aspirin 100mg 1x1R
ATTICUS
Apixaban
Aspirin 100mg 1x1R
- Everybody gets happy!
- Almost half stroke patients get an anticoagulant!
Stroke is a syndrome, not a disease.
Neither a “general” neurologist nor a “general” physician is truly qualified to care for all aspects of stroke, without special training.
We are attracted to the concept of “strokology” as a discipline with specific accreditation.
NOACs, stroke & the future
UNTREATED ON WARFARIN
ON A NOAC
2 3
INRLow Normal High
IS HS ISISHSHS
Courtesy of Dr. Pinachyan
Take-home messages
NOACs are here to stay, to raise new questions & provide answers to unmet needs.
ESUS: potetial new indication for NOACs.
Stroke Medicine is rapidly changing (…and so should we)!