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. 2024 Dec;11(12):3103-3114.
doi: 10.1002/acn3.52217. Epub 2024 Oct 9.

CHA2DS2-VASc score and prior oral anticoagulant use on endovascular treatment for acute ischemic stroke

Yukihiro Imaoka #  1   2 , Nice Ren #  1 , Soshiro Ogata #  3 , Hirotoshi Imamura  4 , Yasuyuki Kaku  2 , Koichi Arimura  5 , Shogo Watanabe  1 , Eri Kiyoshige  3 , Kunihiro Nishimura  3 , Syoji Kobashi  1   6 , Masafumi Ihara  7 , Kenji Kamiyama  8 , Masafumi Morimoto  9 , Tsuyoshi Ohta  10 , Hidenori Endo  11 , Yuji Matsumaru  12 , Nobuyuki Sakai  10 , Takanari Kitazono  13 , Shigeru Fujimoto  14 , Kuniaki Ogasawara  15 , Koji Iihara  1 ; Close The Gap‐Stroke, J‐ASPECT Study Collaborators
Affiliations

CHA2DS2-VASc score and prior oral anticoagulant use on endovascular treatment for acute ischemic stroke

Yukihiro Imaoka et al. Ann Clin Transl Neurol. 2024 Dec.

Abstract

Objective: We evaluated the effect of CHA2DS2-VASc score and prior use of oral anticoagulants (OACs) on endovascular treatment (EVT) in patients with acute ischemic stroke and atrial fibrillation (AF).

Methods: Patients with AF who received EVT in 353 centers in Japan (2018-2020) were included. The outcomes were symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, functional independence, and successful and complete reperfusion. The effects of CHA2DS2-VASc score, its components, and prior use of OACs were assessed via a multiple logistic regression model.

Results: Of the 6984 patients, 780 (11.2%) used warfarin and 1168 (16.7%) used direct oral anticoagulants (DOACs) before EVT. Based on the CHA2DS2-VASc score, 6046 (86.6%) presented a high risk (≥2 for males and ≥3 for females) while 938 (13.4%) had intermediate to low risks. Higher CHA2DS2-VASc scores were associated with increased sICH, in-hospital mortality, and decreased functional independence, regardless of prior OACs. For patients with a high-risk category, prior DOACs increased the odds of successful and complete reperfusion (adjusted odds ratio [95% confidence interval (CI)], 1.27 [1.00-1.61] and 1.30 [1.10-1.53]). For those with integrated intermediate to low risks, neither prior warfarin nor DOAC affected the outcomes. Regardless of total CHA2DS2-VASc scores, patients with congestive heart failure or left ventricular dysfunction, hypertension, age >75 years, or female benefited similarly from prior DOAC use.

Interpretation: Prior DOAC use for patients with high- and selected intermediate-risk CHA2DS2-VASc scores increased prevalence of successful and complete reperfusion. These findings may provide supplemental evidence to introduce preventive DOAC for patients with AF.

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Conflict of interest statement

Dr. Imamura: speakers' bureau/honoraria from Medtronic Japan Co. (which own patent rights to EVT device), Daiichi Sankyo Co. (which own patent rights to DOAC edoxaban), Johnson & Johnson Co. (which own patent rights to EVT device), Stryker Japan Co. (which own patent rights to EVT device), Terumo Co. (which own patent rights to EVT device), and Asahi Intecc Co. (which own patent rights to EVT device). Dr. Ihara: lecturer's fees from Daiichi Sankyo Co. and Eisai (which own patent rights to warfarin), and Bristol‐Myers Squibb (which own patent rights to DOAC apixaban). Dr. Kamiyama: lecturer's fees from Daiichi Sankyo Co. Dr. Ohta reported lecturer's fees from Medtronic, Daiichi‐Sankyo, Johnson & Johnson, Terumo, Stryker Japan, Tokai Medical (which own patent rights to EVT device), Otsuka (which own patent rights to warfarin), Takeda (which own patent rights to warfarin), Eisai (which own patent rights to anticoagulant antagonist), Kaneka (which own patent rights to EVT device), Bristol‐Myers Squibb, AstraZeneca (which own patent rights to anticoagulant antagonist), Japan Lifeline (which own patent rights to EVT device), Nipro (which own patent rights to EVT device), and Century Medical (which own patent rights to EVT device), as well as consulting fees for Johnson & Johnson and Tokai Medical. Dr. Endo: lecturer's fees from Daiichi Sankyo. Dr Matsumaru: lecturer fees from Medtronic, Stryker, Terumo, Kaneka, and Daiichi Sakyo. Dr Sakai: a research grant from Japan Lifeline, Kaneka, Medtronic, Terumo, and TG Medical (which own patent rights to EVT device); lecturer's fees from Asahi‐Intec, Kaneka, Medtronic, Stryker, and Terumo; membership on the advisory boards for Johnson & Johnson, Medtronic, and Terumo. Dr. Kitazono: lecturer's fees and a research grant from Daiichi Sankyo. The remaining authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Patient selection flowchart. AF, atrial fibrillation; AIS, acute ischemic stroke; DOAC, direct oral anticoagulants; LKW, duration from the last time known to be well.
Figure 2
Figure 2
The distribution of CHA2DS2‐VASc score and prevalence of prior DOAC use by gender. (A) The distribution of patients with AF who underwent EVT based on the CHA2DS2‐VASc score by sex is shown. (B and C) The prevalence of OAC treatment and the proportions of warfarin and DOACs are shown by gender. DOAC, direct oral anticoagulants; OAC, oral anticoagulant.
Figure 3
Figure 3
Subgroup analyses of the eight factors constituting the CHA2DS2‐VASc. The marker size represents the total number of participants in each subgroup. The red marker color represents a significant relationship between prior OAC use and unfavorable outcomes while the blue color represents the relationship with favorable outcomes. (A) Analysis for sICH. (B) Analysis for in‐hospital mortality. (C) Analysis for functional independence at 90 days. (D) Analysis for successful reperfusion. (E) Analysis for complete reperfusion. CHF, congestive heart failure; CI, confidence interval; DM, diabetes mellitus; DOAC, direct oral anticoagulants; HT, hypertension; LVD, left ventricular dysfunction; OAC, oral anticoagulants; OR, odds ratio; sICH, symptomatic intracerebral hemorrhage; TE, thromboembolism; TIA, transient ischemic attack.
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