Initiation of oral anticoagulation after acute ischaemic stroke or transient ischaemic attack: timing and complications of overlapping heparin or conventional treatment.
BACKGROUND
Oral anticoagulation is highly effective for secondary prevention of cardioembolic strokes in patients with atrial fibrillation (AF). There are no studies investigating timing and complications of different strategies for initiation of oral anticoagulation after acute stroke or transient ischaemic attack (TIA).


METHODS
Patients of ten community hospitals participating in the prospective evaluation of medical effects of the Telemedical Project for Integrative Stroke Care (TEMPiS) were included. This observational evaluation was restricted to ischaemic stroke or TIA patients with AF who were started on Phenprocoumon treatment during in-hospital stay. Antithrombotic co-medication was dichotomized in heparin bridging (weight or partial thromboplastin time-adjusted heparin) or conventional treatment (antiplatelets and/or low-dose heparin or nil). Besides treatment-relevant extracranial bleeding, major complications were documented according to the European Atrial Fibrillation Trial definitions including vascular death, ischaemic or haemorrhagic stroke, systemic embolism, and myocardial infarction.


RESULTS
Between July 2003 and March 2005, 4,082 ischaemic stroke or TIA patients were admitted. AF was recorded in 961 patients (23.5%), of whom 376 (39.1%) received oral anticoagulation. In 229 of these patients oral anticoagulation was started in hospital, 150 (65.5%) with heparin bridging and 79 (34.5%) with conventional treatment. Patients with heparin bridging were younger, and had a longer in-hospital stay after adjustment for potential confounders (p = 0.01). Major complications were infrequent in both groups (2.0 vs. 2.5%; p = 1.0) as well as extracranial bleeding (3.3 vs. 1.2%; p = 0.43).


CONCLUSIONS
Initiation of oral anticoagulation after acute ischaemic stroke yielded low complication rates independent of antithrombotic co-medication. Heparin bridging was associated with a longer stay in acute care hospitals.
Audebert
Heinrich J
HJ
Stroke Unit, Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK. heinrich.audebert@gstt.nhs.uk
Schenk
Berit
B
Tietz
Viola
V
Schenkel
Johannes
J
Heuschmann
Peter U
PU
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D002545:Brain Ischemia / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D004334:Drug Administration Schedule; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005858:Germany; D006493:Heparin / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D002546:Ischemic Attack, Transient / Q000188:drug therapy* / Q000401:mortality; D007902:Length of Stay; D008297:Male; D010644:Phenprocoumon / Q000008:administration & dosage; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011446:Prospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D016896:Treatment Outcome
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D010644:Phenprocoumon