IV t-PA therapy in acute stroke patients with atrial fibrillation

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Abstract

Background and purpose

Atrial fibrillation (AF) is a predictor for severe stroke. Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke. We investigated clinical characteristics and patient outcome in patients with and without AF after t-PA therapy.

Methods

Consecutive ischemic stroke patients treated with t-PA within 3 h of stroke onset were studied prospectively. MRI examinations, including diffusion weighted imaging and MRA, were performed before t-PA thrombolysis. NIHSS scores were obtained before and 7 days after t-PA infusion. The patients were divided into two groups (AF group and Non-AF group). Their clinical characteristics and outcome 7 days and 3 months after t-PA therapy were compared.

Results

85 patients (56 males, mean age, 73.4 ± 11.5 years) were enrolled in the present study. The AF-group had 44 patients, and the Non-AF group had 41 patients. Fewer patients with AF had dramatic improvement at 7 days and favorable outcome (mRS 0–1) at 3 months after t-PA therapy than patients without AF (31.8% vs. 61.0%, P = 0.007, and 15.9% vs. 46.3%, P = 0.002). On the other hand, worsening at 7 days and poor outcome (mRS > 3 and death) at 3 months after t-PA therapy were more frequently observed in AF group than Non-AF group (22.7% vs. 9.8%, P = 0.107, and 70.5% vs. 41.5%, P = 0.007). After adjusting age and gender, patients with AF more frequently had worsening and poor outcome than those without AF (adjusted OR; 4.54, 95% CI 1.04–19.75, P = 0.044, and adjusted OR; 2.8, 95% CI 1.10–7.28, P = 0.032).

Conclusion

The present study found that acute ischemic stroke patients with AF more frequently had poor outcome after IV-t-PA therapy compared with those without AF.

Introduction

We previously reported that atrial fibrillation (AF) was observed in 21.1% of 15,831 acute ischemic stroke patients in the J-MUSIC study [1] and that AF was a predictive factor for severe stroke and early death [2]. Therefore, attention needs to be paid to the treatment of acute stroke patients with AF in order to improve patients' outcomes. Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke [3], [4]. Early arterial recanalization has been recognized as a marker of a good outcome after t-PA infusion [5], [6], [7], [8], [9], [10]. Using transcranial Doppler (TCD) examination Alexandrov et al. [11] reported that, during t-PA infusion, recanalization was complete in 30% and partial in 40% of patients. Recently, we reported that AF was independently associated with a lack of early recanalization after t-PA administration [12]. Furthermore, using the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial, [3] subanalysis reveled that AF was associated with poor outcome after t-PA therapy [13]. Brown et al. reported that AF was not related with major neurological improvement within 24 h after t-PA infusion [14]. Therefore, we hypothesized that acute stroke patients with AF were less likely to respond to t-PA therapy compared with those without AF. We investigated clinical characteristics and patient outcome after t-PA therapy in acute stroke patients with and without AF.

Section snippets

Subjects and methods

Consecutive patients with acute ischemic stroke treated with t-PA within 3 h of stroke onset between October 2005 and August 2008 were studied prospectively. Patients with heart valve replacements, pacemakers, or cranial artery clipping were excluded, since MRI is contraindicated in these patients.

The following clinical data were collected from all patients: 1) patient age and gender; 2) arterial blood pressure before t-PA infusion; 3) NIHSS score before and 7 days after t-PA infusion; 4) the

Results

A total of 86 consecutive stroke patients were treated with t-PA. One patient was excluded because of having a pacemaker. Thus, 85 patients (56 males, 29 females; mean age, 73.4 ± 11.5 years) were enrolled in the present study. The time from symptom onset to the initial MRI study was 93.6 ± 31.3 min, and the time from symptom onset to the t-PA bolus was 148.0 ± 26.2 min. The baseline NIHSS score was 14.9 ± 7.4.

44 (51.8%) patients (AF group) had AF and 41 (48.2%) patients (Non-AF group) did not have

Discussion

The present study found that acute ischemic stroke patients with AF more frequently had poor outcome after IV-t-PA therapy compared with those without AF. Early arterial recanalization has been recognized as a marker of good outcome after t-PA infusion [5], [6], [7], [8], [9], [10]. Molina et al. [8] reported that early recanalization was more frequent in patients with cardioembolic stroke than with other stroke types. They reported that 59% of cardioembolic strokes displayed recanalization.

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