Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.
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Yaghi Shadi, Shu Liqi, Mandel Daniel, Leon Guerrero Christopher R, Henninger Nils, Muppa Jayachandra, Affan Muhammad, Ul Haq Lodhi Omair, Heldner Mirjam R, Antonenko Kateryna, Seiffge David, Arnold Marcel, Salehi Omran Setareh, Crandall Ross, Lester Evan, Lopez Mena Diego, Arauz Antonio, Nehme Ahmad, Boulanger Marion, Touze Emmanuel, Sousa Joao Andre, Sargento-Freitas Joao, Barata Vasco, Castro-Chaves Paulo, Brito Maria Teresa, Khan Muhib, Mallick Dania, Rothstein Aaron, Khazaal Ossama, Kaufmann Josefin E, Engelter Stefan T, Traenka Christopher, Aguiar de Sousa Diana, Soares Mafalda, Rosa Sara, Zhou Lily W, Gandhi Preet, Field Thalia S, Mancini Steven, Metanis Issa, Leker Ronen R, Pan Kelly, Dantu Vishnu, Baumgartner Karl, Burton Tina, Von Rennenberg Regina, Nolte Christian H, Choi Richard, MacDonald Jason, Bavarsad Shahripour Reza, Guo Xiaofan, Ghannam Malik, Almajali Mohammad, Samaniego Edgar A, Sanchez Sebastian, Rioux Bastien, Zine-Eddine Faycal, Poppe Alexandre, Fonseca Ana Catarina, Baptista Maria Fortuna, Cruz Diana, Romoli Michele, De Marco Giovanna, Longoni Marco, Keser Zafer, Griffin Kim, Kuohn Lindsey, Frontera Jennifer, Amar Jordan, Giles James, Zedde Marialuisa, Pascarella Rosario, Grisendi Ilaria, Nzwalo Hipolito, Liebeskind David S, Molaie Amir, Cavalier Annie, Kam Wayneho, Mac Grory Brian, Al Kasab Sami, Anadani Mohammad, Kicielinski Kimberly, Eltatawy Ali, Chervak Lina, Chulluncuy-Rivas Roberto, Aziz Yasmin, Bakradze Ekaterina, Tran Thanh Lam, Rodrigo-Gisbert Marc, Requena Manuel, Saleh Velez Faddi, Ortiz Gracia Jorge, Mudassani Varsha, de Havenon Adam, Vishnu Venugopalan Y, Yaddanapudi Sridhara, Adams Latasha, Browngoehl Abigail, Ranasinghe Tamra, Dunston Randy, Lynch Zachary, Penckofer Mary, Siegler James, Mayer Silvia, Willey Joshua, Zubair Adeel, Cheng Yee Kuang, Sharma Richa, Marto João Pedro, Mendes Ferreira Vítor, Klein Piers, Nguyen Thanh N, Asad Syed Daniyal, Sarwat Zoha, Balabhadra Anvesh, Patel Shivam, Secchi Thais, Martins Sheila, Mantovani Gabriel, Kim Young Dae, Krishnaiah Balaji, Elangovan Cheran, Lingam Sivani, Quereshi Abid, Fridman Sebastian, Alvarado Alonso, Khasiyev Farid, Linares Guillermo, Mannino Marina, Terruso Valeria, Vassilopoulou Sofia, Tentolouris Vasilis, Martinez-Marino Manuel, Carrasco Wall Victor, Indraswari Fransisca, El Jamal Sleiman, Liu Shilin, Alvi Muhammad, Ali Farman, Sarvath Mohammed, Morsi Rami Z, Kass-Hout Tareq, Shi Feina, Zhang Jinhua, Sokhi Dilraj, Said Jamil, Simpkins Alexis N, Gomez Roberto, Sen Shayak, Ghani Mohammad, Elnazeir Marwa, Xiao Han, Kala Narendra, Khan Farhan, Stretz Christoph, Mohammadzadeh Nahid, Goldstein Eric, Furie Karen
Аннотация
METHODS: This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments.
RESULTS: The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; Pinteraction=0.009).
CONCLUSIONS: Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.