Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study.

Marina Mannino, Leonardo Pantoni, Nemanja Popovic, Antonio Genovese, Umberto Scoditti, Yuriy Flomin, Panagiotis Halvatsiotis, Anastasia Adamou, Efstathia Karagkiozi, Lina Palaiodimou, Anne Falcou, Marco Andrighetti, Francesco Mele, Valeria Terruso, Antonio Gasparro, Andrea Emiliani, Manuel Cappellari, Aurelia Zauli, Marco Moci, Giuseppe Reale, Pietro Caliandro, Fabio Bandini, Annaelle Zietz, Peter Vanacker, Patrik Michel, Valentina Saia, Tiziana Tassinari, Carlo Emanuele Saggese, Sofia Kitmeridou, Kostantinos Vadikolias, Marco Baldini, Nicola Giannini, Vera Volodina, Mario Ferrante, Theodore Karapanayiotides, Andrea Naldi, Alberto Chiti, Vincenzo Mastrangelo, Enrico Maria Lotti, Evangelos Ntais, Maria Kosmidou, Davide Sassos, Massimo Del Sette, Piergiorgio Lochner, Nicola Molitierno, Giorgio Silvestrelli, Costanza Rapillo, Alexander Salerno, Cecilia Becattini, Michele Romoli, Alessandro Pezzini, Elisa Giorli, Sung-Il Sohn, Maurizio Acampa, Francesca Guideri, Rossana Tassi, Alfonso Ciccone, Fanny Simonnet, Sotirios Giannopoulos, Valeria Caso, Michele Venti, Andrea Alberti, Danilo Toni, Maurizio Paciaroni, Alexandros A Polymeris, Michelangelo Mancuso, Stefan T Engelter, Dimitrios Sagris, Ilaria Leone De Magistris, Marina Diomedi, Alessandro Rocco, Elisa Grifoni, Luca Masotti, Georgios Tsivgoulis, Odysseas Kargiotis, Luana Gentile, Andrea Zini, Michele Laudisi, Marina Padroni, George Ntaios, Maria Giulia Mosconi, Jan Rahmig, Daniela Schoene, Kristian Barlinn, Raffaele Ornello, Simona Sacco, Rosario Pascarella, Marialuisa Zedde, Isabella Canavero, Davide Strambo

Journal: European stroke journal 2023;8(4):1030-1040

PMID: 37452632

Abstract

INTRODUCTION

The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group).

PATIENTS AND METHODS

For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days.

RESULTS

Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05-3.18;  = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84-3.47;  = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95-3.73;  = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95-2.85;  = 0.07).

CONCLUSION

Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.

Address: Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.; Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy.; Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.; Stroke Unit, Careggi University Hospital, Florence, Italy.; Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy.; Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milano, Italy.; Neurology Unit, AUSL - IRCCS of Reggio Emilia, Reggio Emilia, Italy.; SSD Neuroradiologia, AUSL - IRCCS of Reggio Emila, Reggio Emilia, Italy.; Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea.; Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.; Department of Neurology, Dresden University Stroke Center, Dresden, Germany.; S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy.; Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy.; IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy.; Stroke Unit, Metropolitan Hospital, Piraeus, Greece.; Second Department of Neurology, "Attikon" Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece.; Stroke Unit, AOU Senese, Siena, Italy.; Internal Medicine, San Giuseppe Hospital, Empoli, Italy.; Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy.; 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece.; Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.; Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.; Department of Neurology, ASL 3 Genovese, Genova, Italy.; Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.; Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy.; Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.; Neurologia, Ospedali Riuniti, Palermo, Italy.; Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy.; Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.; Stroke Unit - Emergency Department, Policlinico Umberto I, Rome, Italy.; Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.; Second Department of Internal Medicine-Propaedeutic and Diabetes Center, Medical School, University General Hospital "Attikon," National and Kapodistrian University of Athens, Greece.; Stroke and Neurorehabilitation Unit MC 'Universal Clinic "Oberig" Kyiv, Kyiv, Ukraine.; Stroke Unit, Emergency Department, University of Parma, Parma, Italy.; Clinic of Neurology, University Clinical Center of Vòsvodina, University of Novi Sad, Novi Sad, Serbia.; Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy.; Department of Neurology, Saarland University, Medical Center, Homburg, Germany.; Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.; IRCCS Ospedale Policlinico San Martino, Genova, Italy.; Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.; Neurology Unit, "Infermi" Hospital, AUSL Romagna, Rimini, Italy.; Neurologia, Ospedale Apuano, Massa Carrara, Italy.; Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy.; NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp, Belgium.; Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.; Groeninge Hospital, Kortrijk, Belgium.; Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.; Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital # 1, Novosibirsk (Russia) at the Novosibirsk State Medical University, Novosibirsk, Russia.; Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy.; Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.; Unità di Terapia Neurovascolare, Ospedale "Fabrizio Spaziani," Frosinone, Italy.; Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy.
Bant logo

© Copyright 2026, Nutrition Evidence

NED wishes to thank the following organisations for their support:

We use cookies to improve your experience and analyze site traffic with Google Analytics. By continuing to use our site, you agree to our use of cookies. Learn more.