Background and Purpose: The availability of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) has changed the therapeutic landscape of anticoagulation therapy, but the guideline-based recommendation of anticoagulation therapy for the acute stroke patients with VTE is unclear. Our aim of this study is to survey clinical characteristics of acute stroke patients with VTE in new treatment paradigms including DOACs.
Methods: Subjects were acute stroke patients within 7 days from onset with VTE detected by enhanced CT and/or ultrasound of leg veins. VTE evaluation was performed for the patients as follows; presence of right-to-left shunts by transcranial Doppler, elevation of D-dimer, and suspected embolic stroke of undetermined source. We analyzed the following information: 1) the prevalence of VTE among acute stroke patients, 2) clinical information of VTE (i.e. subtype and symptom of VTE), 3) treatment details for stroke and VTE, 4) hemorrhagic complication after VTE treatment.
Results: From October 2012 to June 2017, we registered 1077 acute stroke patients. We underwent the VTE evaluation for 226 patients (21%). Of them, 65 patients (39 female, mean age of 76 years, 6% of all patients, and 29% of patients with examination) had VTE (deep vein thrombosis (DVT); 52, pulmonary embolisms (PE); 2, DVT+PE; 11). In 65 patients with VTE, ischemic stroke was 60 cases. Antiplatelet agents were given for 35 of these 60 cases before starting therapy for VTE. Medications for VTE were as follows; 29 cases with DOACs, 14 with warfarin, 7 with warfarin following heparin, and 9 with heparin alone. Hemorrhagic complication occurred in 3 of 60 case of ischemic stroke with VTE (5%). One case had intraventricular hemorrhage after starting DOAC following 200mg aspirin, and muscle hematoma was found in the other two cases using warfarin following heparin.
Conclusions: Prevalence of VTE was 6% of acute stroke patients in our preliminary survey. After medication for acute ischemic stroke with VTE, 5% of them had hemorrhagic complication. We should choose anticoagulation therapy for acute stroke patients with VTE focused on former use of antiplatelet drug and hemorrhagic complication.