title: Anticoagulation after cardioembolic stroke: to bridge or not to bridge?
abstract: BACKGROUND
  Most patients with cardioembolic stroke require long-term anticoagulation. Still, uncertainty exists regarding the best mode of starting long-term anticoagulation. Design, Setting, and Patients We conducted a retrospective review of all patients with cardioembolic stroke admitted to our center from April 1, 2004, to June 30, 2006, and not treated with tissue plasminogen activator. Patients were grouped by treatment: no treatment, aspirin only, aspirin followed by warfarin sodium, intravenous heparin sodium in the acute phase followed by warfarin (heparin bridging), and full-dose enoxaparin sodium combined with warfarin (enoxaparin bridging). Outcome measures and adverse events were collected prospectively. Laboratory values were captured from the records.
  
  
  METHODS
  Symptomatic hemorrhagic transformation, stroke progression, and discharge modified Rankin Scale score.
  
  
  RESULTS
  Two hundred four patients were analyzed. Recurrent stroke occurred in 2 patients (1%). Progressive stroke was the most frequent serious adverse event, seen in 11 patients (5%). Hemorrhagic transformation occurred in a bimodal distribution-an early benign hemorrhagic transformation and a late symptomatic hemorrhagic transformation. All of the symptomatic hemorrhagic transformation cases were in the enoxaparin bridging group (10%) (P = .003). Systemic bleeding occurred in 2 patients (1%) and was associated with heparin bridging (P = .04).
  
  
  CONCLUSIONS
  Anticoagulation of patients with cardioembolic stroke can be safely started with warfarin shortly after stroke. Heparin bridging and enoxaparin bridging increase the risk for serious bleeding.
authors.affiliation: Department of Neurology, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 7.044, Houston, TX 77030, USA. hen.hallevi@uth.tmc.edu
authors.forename: Hen
authors.initials: H
authors.lastname: Hallevi
authors.forename: Karen C
authors.initials: KC
authors.lastname: Albright
authors.forename: Sheryl
authors.initials: S
authors.lastname: Martin-Schild
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Barreto
authors.forename: Sean I
authors.initials: SI
authors.lastname: Savitz
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Escobar
authors.forename: Nicole R
authors.initials: NR
authors.lastname: Gonzales
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Noser
authors.forename: Kachi
authors.initials: K
authors.lastname: Illoh
authors.forename: James C
authors.initials: JC
authors.lastname: Grotta
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000139:chemically induced / Q000473:pathology; D004617:Embolism / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012189:Retrospective Studies; D020521:Stroke / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D013997:Time Factors
chemical_list: D000925:Anticoagulants