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Abstract Details

Anticoagulation Choice and Timing in Stroke Due to Atrial Fibrillation: A Survey of US Stroke Specialists (ACT-SAFe)
Cerebrovascular Disease and Interventional Neurology
S35 - Stroke Prevention Strategies (1:00 PM-1:11 PM)
001
Risk of early recurrence of ischemic stroke due to atrial fibrillation may be high. ASA/AHA guidelines provide imprecise recommendations on the timing and anticoagulant choice for this indication. 
We assessed current opinions of stroke neurologists.

Case scenarios describing patients with acute ischemic stroke (AIS) of varying severity and hemorrhagic transformation (HT) incidence due to non-valvular paroxysmal atrial fibrillation (PAF) were presented to all US board-certified stroke neurologists in an internet-based questionnaire. Questions assessed timing and choice of anticoagulation for secondary stroke prevention, factors prompting earlier anticoagulation, reasons for specific anticoagulant choice and alternatives to anticoagulation in ineligible patients. Open-ended comments were solicited.

Responses were available from 238 of 1239 surveyed. In patients with small AIS <1/3 MCA territory without HT, only 24% would start anticoagulation within 48 hours from stroke onset, although 80% anticoagulated by 7 days. With increased stroke severity >1/2 MCA territory, fewer (29%) chose to anticoagulate within 7 days, 48% waited 7-14 days, and 23% delayed >14 days. Some requested stability imaging before anticoagulating. Asymptomatic HT did not appreciably affect anticoagulation timing, but with symptomatic HT by SITS-MOST criteria, majority (79%) waited >14 days. Most anticoagulated earlier than initially intended if left atrium/left atrial appendage, acute left ventricular thrombi, or mechanical heart valve were present.  Direct oral anticoagulants (DOACs) were the preferred anticoagulation strategy (62%), and low bleeding risk, affordability/cost and availability of a specific reversal agent were the most common reasons cited (82%, 55%, 42% respectively). Aspirin was preferred by 57% in anticoagulation ineligible. 

Apart from AIS with symptomatic HT, there is a remarkable lack of consensus among stroke neurologists regarding the timing of anticoagulation for secondary stroke prevention in patients with AIS due to non-valvular PAF. DOACs are the preferred anticoagulation strategy. More studies are required to clarify anticoagulant management in this patient population.
Authors/Disclosures
Igor Rybinnik, MD (Rutgers Robert Wood Johnson Medical School)
PRESENTER
Dr. Rybinnik has nothing to disclose.
Deviyani Mehta, MD Dr. Mehta has nothing to disclose.
Michael T. Mullen, MD (Temple University) Dr. Mullen has received publishing royalties from a publication relating to health care.
Steven R. Messe, MD, FAHA, FAAN (Hospital of the University of Pennsylvania) Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novo Nordisk. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Terumo. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for WL Gore. The institution of Dr. Messe has received research support from WL Gore. The institution of Dr. Messe has received research support from Mallinkrodt. The institution of Dr. Messe has received research support from Biogen. Dr. Messe has received intellectual property interests from a discovery or technology relating to health care. Dr. Messe has received publishing royalties from a publication relating to health care. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving as a Clinical Event Committee for the CONFORMAL left atrial appendage occlusion trial with Yale Cardiovascular Research Group.
Scott E. Kasner, MD, FAAN (University of Pennsylvania) Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Bristol-Myers Squibb. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Diamedica. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Abbvie. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for AstraZeneca. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Javelin. Dr. Kasner has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for UpToDate. The institution of Dr. Kasner has received research support from Bristol-Myers Squibb. The institution of Dr. Kasner has received research support from Medtronic. The institution of Dr. Kasner has received research support from WL Gore.
Ronen R. Leker, MD No disclosure on file
Brett L. Cucchiara, MD (Hosp Uni of Pennsylvania) Dr. Cucchiara has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Elseiver. Dr. Cucchiara has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Bayer. Dr. Cucchiara has received publishing royalties from a publication relating to health care.