Cardioembolic Stroke

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Cardioembolic Stroke

Andre Douen MD, PhD, FRCPC, FAHAAdjunct Professor, University of Ottawa,

Director West GTA Regional Stroke Program,Chief, Division of Neurology,

Trillium Health Centre, Mississauga

Case 1 Mrs W.S., LLM

• 62 y/o obese lawyer with GERD • PMH:

– Smoking 1ppd x 30 yrs– No HTN, No DM, No Cholesterol at her last visit in

Jan 2010

Case 1 Mrs W.S.• HPI

Speaking with niece regarding a legal matter when.. Slurred speech Loss of speech Right facial droop, Right arm weak and incoordinated

• EMS Symptoms resolved with 15 min Patient declines transfer to ER Elects to wait overnight and call fam doc in AM for a

quick visit and head to office after to prepare for prosecuting a medico-legal case

Case 1

Examination in office the next day:

BP = 160/90 ; HR 90 and regular. No neurological deficits, but with right carotid Bruits.Current Meds: Losec, Tylenol prn for back pain

Diagnosis: TIA

Case 1• Needs to get back to office ASAP• Thinks this “TIA” thing is non-sense, as she feels she

was a bit stressed over the case and that caused her symptoms

• Not keen on extensive investigations for such a minor episode

• She might comply if she can schedule these in between her practice over the next 2 months

• If it was a “TIA” (she is skeptical) then she wants to estimate her risk of recurrence

Q1. What do you think her stroke risk might be within the next month:

a. ~ 2%b. ~ 8%c. ~ 20%d. She’ll almost certainly re-strokee. Her risk can only be measured over 3 months

Q1. What do you think her stroke risk might be with in the next month:

a. ~ 2%b. ~ 8%c. ~ 20%d. She’ll almost certainly re-strokee. Her risk can only be measured over 3 months

Stroke Recurrence • Antecedent stroke/TIA is the most significant

indicator of a possible recurrent stroke• High incidence of early recurrent stroke

following either TIA or minor stroke• Early recognition and treatment significantly

reduces the risk of stroke recurrence

Johnston et al. JAMA 2000; 284: 2901–2906.Warach, Kidwell. Neurology 2004; 62: 359–360.

Mohr. Neurology 2004; 62 (8 Suppl 6): S3–S6.

The ABCD2 Score

Indicator Criteria Score

A Age 1 point for age 60 /1B Blood pressure 1 point for BP >140/90 mmHg /1C Clinical features 2 points for focal weakness or

1 point for speech disturbance /2

D Duration of symptoms 1 point for duration 10-59 minutes2 points for duration >60 minutes

/2

D Diabetes 1 point for presence of diabetes /1 Total Score /7

The ABCD2 Score

Indicator Criteria Score

A Age 1 point for age 60 /1B Blood pressure 1 point for BP >140/90 mmHg /1C Clinical features 2 points for focal weakness or

1 point for speech disturbance /2

D Duration of symptoms 1 point for duration 10-59 minutes2 points for duration >60 minutes

/2

D Diabetes 1 point for presence of diabetes /1 Total Score /7

1

1

2

1

0

5

Risk Factors for Stroke Within 90 Days of a TIAThe ABCD2 Score

0

5

10

15

20

25

0 1 2 3 4 5 6 7

2 Days7 Days30 Days90 Days

StrokeRisk(%)

ABCD2 Score

LowRisk

HighRisk

IntermediateRisk

• Lancet 2007;369:283-92.

CT brain : Nil acute.

ECG : AF with HR of 95

Is a Doppler still required ??

What is incidence and prevalence of AF??

Meds : ???

CT brain : Nil acute.

ECG : AF with HR of 95

Is a Doppler still required ?? YES

What is incidence and prevalence of AF ??

Meds : ???

Both Incidence/Prevalence increases with age.•Estimated Prevalence:

– ~1% of general population, 0.1% < 60 years of age– 1-4% 60-80 years of age– 9% > 80 years of age

•Estimated Incidence:– 50 years of age: 0.5% /1000 /year – 70 years of age: 9.7% /1000 /year

•Gender: Male > Female•Overall AF affects:

– ~200,000 - 250,000 Canadians – 2.2 million Americans

EPIDEMIOLOGY

Cardioemboli

• AF : – High incidence of paroxysmal AF in acute stroke– 13.5% detection of new onset AF– Overall ~20 % of acute stroke patient with AF

(Douen et al, Stroke 2008)

• Up to 3 million people worldwide suffer strokes related to AF each year1-3

1. Atlas of Heart Disease and Stroke, World Health Organization, September 2004. Viewed at http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf

2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 2. 1991:22(8);983-8

3. Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996;27:1760-4

http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf

AF increases the risk of stroke• AF is associated with a pro-thrombotic state

– ~5-17 fold increase in stroke risk

• Risk of stroke is the same in patients with chronic of PAF

• There is a high 30-day mortality (~25%) following cardioembolic stroke

• AF-related stroke has a 1-year mortality of ~50%1. Wolf PA, et al. Stroke 1991;22:983-988; 2. Rosamond W et al. Circulation. 2008;117:e25–146; 3.Hart RG, et al. J Am Coll Cardiol 2000;35:183-187; 4. Lin H-J, et al. Stroke 1996; 27:1760-1764; 5. Marini C, et al. Stroke 2005;36:1115-1119.

Q2. Because of high risk of spontaneous GI bleeds from angiodysplasia and spontaneous intracranial hemorrhages OAC should be used with extreme caution or not at all in elderly patients (> 80 yrs old) with AF

– True – False

Q3. The patients who benefit the most from OAC therapy are those with AF in the age group 65-75 and with no other medical issues.

– True– False

Q2a. Because of high risk of spontaneous GI bleeds from angiodysplasia and spontaneous intracranial hemorrhages OAC should be used with extreme caution or not at all in elderly patients (> 80 yrs old) with AF

– True – False

Q3a. The patients who benefit the most from warfarin therapy are those with AF in the age group 65-75 and with no other medical issues.

– True– False

Q4. Recent studies have shown that ASA+Plavix is superior to ASA alone and equally efficacious to warfarin for cardio-embolic (AF) stroke prophylaxis.Warfarin = ASA+Plavix > ASA

– True– False

Q4a. Recent studies have shown that ASA+Plavix is superior to ASA alone and equally efficacious to warfarin for cardio-embolic (AF) stroke prophylaxis.Warfarin = ASA+Plavix > ASA

– True– False

CCS 2012 Update to AF Guidelines

CHADS2 = 0

*Aspirin is a reasonable alternative in some as indicated by risk/benefit

CHADS2 = 1 CHADS2 ≥ 2

No anti-thrombotic

Assess Thromboembolic Risk (CHADS2)

No additional

risk factors for stroke

Increasing stroke risk

ASA OAC* OAC* OAC*

Either female sex or vascular

disease

Age ≥ 65 yrs or combination

of female sex and vascular

disease

*OAC = Oral anticoagulant ASA = Aspirin

Consider stroke risk vs. bleeding risk

Only when the stroke risk is low and bleeding risk is high does the risk/benefit ratio favor no antithrombotic therapy

1. Skanes AC, et al. Can J Cardiol 2012;28:125-136.

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CHADS2 acronym CHA2DS2-VASc acronym HAS-BLED acronym

Feature Score Feature Score Feature Score

Congestive heart failure 1 Congestive Heart Failure 1 Hypertension (Systolic ≥160mmHg) 1

Hypertension 1 Hypertension 1 Abnormal renal function 1

Aged ≥75 years 1 Age ≥ 75 years 2 Abnormal liver function 1

Diabetes mellitus 1 Diabetes mellitus 1 Stroke in past 1

Stroke/TIA/ /Thrombo-embolism 2 Stroke/ TIA/ Thrombo-

embolism 2 Bleeding 1

Vascular disease 1 Labile INRs 1

Age between 65 and 74 years 1 Elderly (Age ≥ 65 years) 1

Female 1 Drugs (anti-platelet or NSAIDs) 1

Alcohol intake at same time 1

Maximum score 6 Maximum score 9 Maximum score 9

Case 1

Mrs W.S. Risk: 62-year-old - < 75 : 0HTN : 1No h/o CHF : 0No DM : 0TIA symptoms : 2

CHADS Risk = 3

CHADS-VASC Risk = 4 (HTN, F, Stroke symptoms)

Q5. For patient with cardioembolic (AF) stroke/TIA which of the following Antithrombotic Regimens are recommended for secondary prevention

a. Warfarin b. Warfarin + ASAc. Warfarin + clopidorgrel b. Dabigatran (Pradax)c. Rivaroxaban (Xaralto)e. Apixaban (Eliqus)f. All of the above

1. Haas S. J Thromb Thrombolysis. 2008;25:52-60.2. Adapted from Ezekowitz MD et al. Mayo Clin Proc. 2004;79:904-913.

Narrow efficacy window + multiple interactions

Challenges of Oral Anticoagulation Therapy (OAC)

hard to use/take1=

ISCHEMIC STROKE INTRACRANIAL BLEED

Odd

s R

atio

05.0 6.0 8.0

INR1.0 2.0 3.0 4.0 7.0

5.0

15.0

10.0

1.0

20.0

Warfarin for Atrial Fibrillation

Samsa GP, et al. Arch Intern Med 2000;160:967.

INR above target6%

Subtherapeutic INR 13%

INR intarget range

15%

No warfarin

65%

Adequacy of Anticoagulation inPatients with AF in Primary Care Practice

Underutilisation of VKA despite prior TIA or stroke

Adapted from Gladstone et al. Stroke 2009;40:235-40.

AF patients with previous TIA or ischaemic stroke, considered to be suitable for anticoagulation and admitted with acute ischaemic stroke (Ontario 2003-2007)

n=323

No antithrombotics 15%

Dual antiplatelet therapy 3%

Single antiplatelet agent 25%

Warfarin–therapeutic 18%

Warfarin–subtherapeutic 39%

The TTR is only ~50% in a global AF registry

Suboptimal INR control worldwide (2008-2011)

67 594754

3840 363444

** * ***

*p≤0.005 vs. North America INR <2.0

N=1802 N=1127 N=1975 N=2536 N=896 N=1089 N=2520 N=1951 N=1278

Adapted from Healey et al. Presented at the ESC meeting on Sunday August 28, 2011 - http://spo.escardio.org/eslides/view.aspx?eevtid=48&fp=1355

INR =2.0-3.0 INR >3.0

Tremblay, Sandra

échelle?

New OAC• Dabigatran Etexilate (Direct Thrombin Inhibitor) in Atrial Fibrillation (RE-LY)

• Rivaroxaban (Factor Xa inhibitor)in Atrial Fibrillation (ROCKET-AF)

• Apixaban (Factor Xa inhibitor)in Atrial Fibrillation (AVERROES; ARISTOTLE)

Pros : No Monitoring Rapid onset of action Similar or better bleeding profile to

warfarinCon : No antidote, no clear way of measuring effect

Clinical program to demonstrate the efficacy & safety of apixaban for the prevention of stroke & SE in

NVAF patients1

• A total of 23,799 patients were randomised in the clinical program, including 11,927 randomised to apixaban1

*Patients with ≥2 of the following: age ≥80 years, body weight ≤60 kg, or a serum creatinine level ≥1.5 mg/dL (133 μmol/L)1. Apixaban SmPC 2012. 2. Granger et al. N Engl J Med 2011;365:981-92. 3. Connolly et al. N Engl J Med 2011;364:806-17.

ARISTOTLE2 AVERROES3

Randomised, double-blind, double-dummy, active control, multinational trial

Randomised, double-blind, double-dummy, active control, multinational trial

In more than 18,000 patients with NVAF In more than 5500 patients with NVAF

Who were suitable for VKA therapy Who were unsuitable for VKA therapy

Receive either apixaban 5.0 mg BD (or 2.5 mg BD in selected patients*) or warfarin (INR, target: 2.0-3.0)

Receive either apixaban 5.0 mg BD (or 2.5 mg BD in selected patients*) or ASA 81-324 mg

ARISTOTLE: Apixaban was superior to warfarin in preventing stroke or systemic embolism

No. at riskApixaban 9,120 8,726 8,440 6,051 3,464 1,754Warfarin 9,081 8,620 8,301 5,972 3,405 1,768

Patie

nts w

ith e

vent

(%)

Months

Apixaban

Warfarin

0 6 12 18 24 30

0

1

2

3

4

HR 0.79 (95% CI: 0.66-0.95)

p<0.001 for non-inferiorityp=0.01 for superiority

21% RRR

Adapted from Granger et al. N Engl J Med 2011;365:981-92.

ARISTOTLE: Apixaban significantly reduced the risk of major bleeding* vs. warfarin

* Major bleeding was defined according to ISTH criteria Adapted from Granger et al. N Engl J Med 2011;365:981-92.

No. at riskApixaban 9088 8103 7564 5365 3048 1515Warfarin 9052 7910 7335 5196 2956 1491

Apixaban

Patie

nts w

ith e

vent

(%)

Months

Warfarin

0 6 12 18 24 30

0

2

4

6

8

HR 0.69 (95% CI: 0.60-0.80); p<0.001

31% RRR

AVERROES: Study Design1,2

• The primary objective of the trial was to determine if apixaban was superior to ASA for the prevention of the composite outcome of stroke or systemic embolism.– Primary efficacy outcome: Stroke or systemic embolism – Primary safety outcome: Major bleeding

*Patients with ≥2 of the following: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL (133 μmol/L). **The selection of an ASA dose of 81, 162, 243, or 324 mg was at the discretion of the investigator with 91% of subjects receiving either an 81-mg (64%) or 162-mg (27%) dose at randomisation. 1. Apixaban SmPC. 2. Connolly et al. N Engl J Med 2011;364:806-817.

Patient Population• Patients ≥50 years with NVAF

and ≥1 risk factors for stroke• Not receiving VKA therapy

(demonstrated or expected to be unsuitable for VKA)

Apixaban 5.0 mg oral BID(2.5 mg in select patients* [6.4%])

Event Driven*

Randomised, double-blind,double-dummy

ASA 81-324 mg QD**

N=5599Mean follow-up: 1.1 years

Date of preparation: December 2012

No. at riskApixaban 2808 2758 2566 2125 1522 615Aspirin 2791 2716 2530 2112 1543 628

AVERROES: Apixaban was superior to ASAin preventing stroke or systemic embolism*

*Primary efficacy outcomeAdapted from Connolly et al. N Engl J Med 2011;364:806-17.

Apixaban

Cum

ulati

ve H

azar

d

Months

ASA

0 3 6 9 12 30

0.00

0.01

0.02

0.04

0.05

HR 0.45 (95% CI: 0.32-0.62)

p<0.001 for superiority

55% RRR

0.03

Recent Oral Anticoagulation Trials:Stroke or Systemic Embolism

Apixaban not yet approved in Canada for stroke prevention in patients with atrial fibrilliation

The new oral anticoagulant agents are consistently associated with a numerically lower risk for stroke or systemic embolism compared to warfarin†

Data obtained from intention-to-treat analysis†Not intended as cross-trial comparison

1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.2. Patel MR, et al. N Engl J Med 2011;365:883-891.3. Granger C, et al. N Engl J Med 2011;365:981-992

Recent Oral Anticoagulation Trials:Hemorrhagic Stroke

Apixaban not yet approved in Canada for stroke prevention in patients with atrial fibrilliation

The new oral anticoagulants are consistently associated with a numerically lower risk of hemorrhagic stroke compared with warfarin†

Data obtained from intention-to-treat analysis†Not intended as cross-trial comparison


Recent Oral Anticoagulation Trials:Major Bleeding

HR (95% CI)New Agent Better Warfarin Better

Apixaban not yet approved in Canada for stroke prevention in patients with atrial fibrilliationData obtained from intention-to-treat analysis†Not intended as cross-trial comparison



When oral anticoagulant therapy is indicated, most patients should receive dabigatran, rivaroxaban, or apixaban, in

preference to warfarin

• Dabigatran and apixaban have greater efficacy and rivaroxaban has similar efficacy for stroke prevention

• Dabigatran and rivaroxaban have no more major bleeding and apixaban has less

• All three new oral anticoagulants have less intracranial hemorrhage and are much simpler to use



GFR Warfarin Dabigatran Rivoraxaban Apixaban

GFR ≥ 60 mL/min Dose adjusted for INR 2.0-3.0 150 mg BID or 110 mg BID 20 mg daily 5 mg BID

GFR 50-59 mL/min Dose adjusted for INR 2.0-3.0 150 mg BID or 110 mg BID 20 mg daily 5 mg BID

GFR 30-49 mL/min Dose adjusted for INR 2.0-3.0 150 mg BID or 110 mg BID 15 mg daily

5 mg BID (for GFR >25 ml/min only Consider 2.5 mg BID†

GFR 15-29 mL/min (not on dialysis) No RCT data‡ No RCT data§ No RCT data¶

5 mg BID (for GFR >25 ml/min only Consider 2.5 mg BID†

GFR < 15 mL/min (on dialysis) No RCT data‡ No RCT data¶ No RCT data¶ No RCT data

†Consider Apixaban 2.5 mg po bid if GFR ≤ 25 mL/min, especially if age > 80 or body weight < 60 kg‡Dose adjusted warfarin has been used, but observational data regarding safety and efficacy is conflicting§Modelling studies suggest that dabigatran 75 mg bid might be safe for patients with GFR 15-29 mL/min; not been validated in a prospective cohort¶No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function


Case 1

Mrs W.S. Risk: 62-year-old - < 75: 0HTN : 1No h/o CHF : 0No DM : 0TIA symptoms : 2

CHADS Risk = 3

CHADS-VASC Risk = 4 (HTN, F, Stroke symptoms)

Case 1

Patient started on warfarin (physician decision) because has “no insurance”; CrCl 37

INRs Q 2 weeks with many absent readings due to busy schedule :April 15 = 2.7 April 30th = 3.4May 15 = 1.7 May 30th = no readingJune 15th = 1.6 June 30th = 3.2July 15th = no reading

Scenarios and treatment options#1

August 2nd patient asymptomatic but comes in for regular f/u visit.

Options:i. Repeat labs (CBC, CrCl, INR)ii. Discuss strategies for adherence and

“optimizing” INR levelsiii. Switch ? (safety, LU, compliance)


August 2nd admitted with L sided paralysis. CT brain normal, symptoms resolve slowly over 2hrs; INR 1.6. Diagnosis TIA

Options:i. Repeat labs (CBC, CrCl)ii. Discuss strategies for adherence and



August 2nd admitted with L sided paralysis. CT brain normal, symptoms resolve slowly over 2hrs; INR 2.3

Options:i. Other labs (CBC, Cr, CrCl)ii. Persist with warfarin but discuss strategies for

adherence and “optimizing” INR levelsiii. Switch ? (safety, LU, compliance)


Patient asymptomatic but comes in for regular f/u visit; ; CrCl now 30

Options:i. Other labs (CBC, INR)ii. Discuss strategies for adherence and

“optimizing” INR levelsiii. Switch ? (safety, LU, compliance, CrCl)


Admitted with mild L sided weakness. CT brain shows small R basal ganglia ischemic insult; INR 1.6, CrCl 40

Options:i. Other labs (CBC)ii. Discuss strategies for adherence and



August 2nd admitted with mild L sided weakness CT brain shows small R basal ganglia ischemic insult; INR 2.3 , CrCl 40

Options:i. Other labs (CBC)ii. Discuss strategies for adherence and


Q6. Patients with AF who has spontaneous intracranial hemorrhage while using OAC should never be placed back on OAC

– True– False


Admitted with mild L sided weakness CT brain shows small R basal ganglia bleed; INR 4.5, CrCl 40

Options:i. Repeat labs (CBC)ii. D/C Warfariniii. Other history ??iv. OAC ??

Scenarios and treatment options #8.

August 2nd admitted with mild L sided weakness CT brain shows small R basal ganglia bleed; INR 2.5, CrCl 40

Options:i. Repeat labs (CBC)ii. D/C Warfariniii. Other history ??iv. Other OAC ??


Patient asymptomatic, on OAC but HGB has declined from 140 to 115. INR 2.3, CrCl 40

Options:i. Repeat labs (CBC)ii. D/C Warfarin ??iii. Other history ?? iv. Other investigations ??v. Other OAC ??


When and what anticoag should be started if:a. Acute minor ischemic stroke with new onset AF.

CrCl 60. b. Acute large ischemic stroke with new onset AF.

CrCl 60c. Moderate acute ischemic stroke with DVT detected

within 3 days post-admissiond. Minor acute ischemic stroke with history of EtOH

abuse and bleeding ulcer, treated 6 months before and sober for 7 months. Plts 120, HbG 110

Stroke prevention in AFUse of reduced dose of various

new oral anticoagulants in AF patients Apixaban1 Rivaroxaban2 Dabigatran3

Recommended daily dose

5 mg bid 20 mg od

Taken with food

150 mg bid

Dose reduction 2.5 mg bid

if ≥2 of the following:• Age ≥80 years, • Body weight ≤60 kg, • Serum creatinine

≥1.5 mg/dL (133 µmol/L)

15 mg od

Taken with food

In patients withmoderate renal impairment (CrCl: 30-49 mL/min)

110 mg bid

• Age ≥80 yrs• Increased bleeding risk and• Age ≥80 yrs• Age ≥75 yrs with at least one other risk

factor for bleeding• Patients with an increase risk of

bleeding: age ≥75 years, moderate renal impairment (30-50 ml CrCL/min), concomitant treatment with strong P-gp inhibitors, antiplatelets or previous gastro-intestinal bleed.

CrCl: creatinine clearance / The information in this table is based on the PM for apixaban, rivaroxaban and dabigatran. Please refer to the individual PM for further information. 1. Eliquis, PM 2012. 2. Rivaroxaban, PM 2012. 3. Dabigatran, PM 2012

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• 1 point for Congestive Heart Failure• 1 point for Hypertension• 1 point for Age ≥ 75 years• 1 point for Diabetes Mellitus • 2 points for Prior Stroke or TIA

CHADS2 Score(Simple Prediction Tool for Assessing Stroke Risk)

CHADS2 Score* Stroke Rate, %/yr(95 %CI)

0 1.9 (1.2 – 3.0)

1 2.8 (2.0 – 3.8)

2 4.0 (3.1 – 5.1)

3 5.9 (4.6 – 7.3)

4 8.5 (6.3 – 11.1)

5 12.5 (8.2 – 17.5)

6 18.2 (10.5 – 27.4)*Score 0: Patients can be administered aspirin*Score 1: Patients can be administered aspirin or anticoagulant

therapy*Score ≥2: Patients should be administered anticoagulant therapy

1. Gage BF, et al. JAMA. 2001;285:2864-2870

CHA2DS2-VASc Score

• 1 point for Congestive Heart Failure/LV Dysfunction

• 1 point for Hypertension• 2 points for Age ≥ 75 years• 1 point for Diabetes Mellitus • 2 points for Prior Stroke or TIA1 or TE2

• 1 point for Vascular Disease3

• 1 point for Age 65-74 years• 1 point for Sex category (female gender)

CHA2DS2-VASc Score*

One year event rate (95% CI) of hospital admission and death due to

thromboembolism† per 100 person years

0 0.78 (0.78 – 1.04)

1 2.01 (1.70 – 2.36)

2 3.71 (3.36 – 4.09)

3 5.92 (5.53 – 6.34)

4 9.27 (8.71 – 9.86)

5 15.26 (14.35 – 16.24)

6 19.74 (18.21 – 21.41)

7 21.5 (18.75 – 24.64)

8 22.38 (16.29 – 30.76)

9 23.64 (10.62 – 52.61)*Score 0: Patients can be administered aspirin*Score 1: Patients can be administered aspirin or anticoagulant therapy*Score ≥2: Patients should be administered anticoagulant therapy†Includes peripheral artery embolism, ischemic stroke, and pulmonary embolism

1TIA = Transient ischemic attack; 2TE = Thromboembolism3Prior myocardial infarction, peripheral artery disease, aortic plaque1. Lip GY et al. Chest 2010;137:263-272

2. Olesen JB, et al. BMJ 2011;342:d1243. Task Force or the Management of Atrial Fibrillation of the ESC. Eur Heart J 2010;31:236902429

• A bleeding risk assessment should be performed in all patients prior to prescribing antithrombotic therapy

• Bleeding risk assessment tools, such as the HAS-BLED* are available

• A high score indicates a higher risk of bleeding, but should not preclude the use of an anticoagulant in patients at risk for stroke

Bleeding risk assessment

*In HAS-BLED, major bleeding was defined as fatal or clinically overt bleeding associated with either transfusion of ≥ 2 U of blood or ≥ 20 g/l decrease in hemoglobin or bleeding involving a critical anatomic site other than the brain parenchyma

1. Pisters R, et al. Chest 2010; 138(5):1093–1100

HAS-BLED Bleeding Score(Simple Tool for Assessing Bleeding Risk)

Letter Clinical Characteristic* Points Awarded: Score

H Hypertension 1A Abnormal renal or liver function (1 point each) 1 or 2S Stroke 1B Bleeding 1L Labile INRs 1E Elderly 1D Drugs or alcohol (1 point each) 1 or 2

*Hypertension - uncontrolled, >160 mm Hg systolic; Abnormal renal/liver function (one point for presence of renal or liver impairment, maximum two points); Stroke (previous history, particularly lacunar); Bleeding history or predisposition (anemia); Labile international normalized ratio (INR) (i.e. therapeutic time in range < 60%); Elderly ( >65 years); Drugs/alcohol concomitantly (antiplatelet agents, nonsteroidal anti-inflammatory drugs; one point for drugs plus one point for alcohol excess, maximum two points).

1. Pisters R, et al. Chest 2010; 138(5):1093–1100

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