Stroke in the era of NOACs

George Ntaios MD, MSc (Stroke Medicine), PhD

University of Thessaly, Greece

Oslo11/12/2015

Disclosures

Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim.Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Elpen; BayerSupport to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; BMS Participation in trials:

– NAVIGATE-ESUS / National Coordinator (Greece)– GLORIA-AF / Sub-investigator (Larissa).– FOURIER / Principal investigator (Larissa).– PRECIOUS / National Coordinator (Greece).– ENOS / National Coordinator (Greece).– EBBINGHAUS / Principal Investigator (Larissa).– BIOSIGNAL / Principal Investigator (Larissa).– PREVISE / Principal investigator (Larissa).

Hercules and Lernaean Hydraby Lorenzo Matialli, Habsburg Palace, Vienna

Anticoagulation after AF-stroke: how soon (or late?)

Anticoagulation after AF-stroke: how soon (or late?)

Anticoagulation after AF-stroke: how soon (or late?)

Reasons to start early

• Low NIHSS • Small/no brain infarction on MRI• High recurrence risk e.g. thrombus on

echo• No haemorrhagic transformation• Patient is clinically stable• Young patient• Blood pressure is controlled

Reasons to wait

• High NIHSS • Large/moderate brain infarction• Haemorrhagic transformation• Neurologically unstable• Elderly patient• Uncontrolled hypertension

The 1-3-6-12 rule

TIA 1 day

Small infarct 3 days

Moderate infarct 6 days

Large infarct 12 days

NOACs could be the answer?

Ntaios et al. Stroke 2012

Intracranial haemorrhage while on anticoagulants

ESO ICH Guidelines

Steiner et al. Int J Stroke. 2014

Ntaios et al. Int J Stroke. 2015;Suppl A100:128-35

ESO ICH Guidelines

Steiner et al. Int J Stroke. 2014

NOACs could be the answer?

Ntaios et al. Stroke 2012

Ntaios & Lip. Curr Opin Neurol 2015

Our patient (… and his grand-grand-son)

81yrs

Fully independent at 3months

Hypertensive, Non-smoker, non-diabetic

LDL: 104mg/dl

LA diameter: 42mm

Triplex: -

24hrs ECG: -

Hart et al. Lancet Neurol 2014; 13: 429–38

ESUS: Embolic Strokes of Undetermined Source

ESUS: diagnostic criteria

Stroke detected by CT or MRI that is not lacunar.

Absence of extracranial or intracranial atherosclerosis causing >50% luminal stenosis in arteries supplying the area of ischemia.

No major-risk cardioembolic source of embolism (permanent or paroxysmal AF, sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, atrial myxoma or other cardiac tumours, mitral stenosis, recent (<4 weeks) MI, LVEF<30%, valvular vegetations, or infective endocarditis).

No other specific cause of stroke identified.

Hart et al. Lancet Neurol 2014; 13: 429–38

ESUS: potential causes

Hart et al. Lancet Neurol 2014; 13: 429–38

Hart et al. Lancet Neurol 2014; 13: 429–38

ESUS: Embolic Strokes of Undetermined Source

ESUS in the Athens Stroke Registry

Ntaios et al. Stroke 2015; 46:176-81

ESUS: stroke severity

Ntaios et al. Stroke 2015; 46:176-81

ESUS: 5-yrs functional outcome

Ntaios et al. Stroke 2015; 46:2087-93

ESUS: 5-yrs stroke recurrence

Ntaios et al. Stroke 2015; 46:2087-93

So, how to treat my ESUS patient?

Furie et al. Stroke 2011;42:227-76

Approach 1

So, how to treat my ESUS patient?

Approach 2

So, how to treat my ESUS patient?

Approach 3

RESPECT - ESUS

Dabigatran 110/150 1x2

Aspirin 100mg 1x1R

NAVIGATE - ESUS

Rivaroxaban 15mg 1x1

Aspirin 100mg 1x1R

ATTICUS

Apixaban

Aspirin 100mg 1x1R

- Everybody gets happy!

- Almost half stroke patients get an anticoagulant!

Stroke is a syndrome, not a disease.

Neither a “general” neurologist nor a “general” physician is truly qualified to care for all aspects of stroke, without special training.

We are attracted to the concept of “strokology” as a discipline with specific accreditation.

NOACs, stroke & the future

UNTREATED ON WARFARIN

ON A NOAC

2 3

INRLow Normal High

IS HS ISISHSHS

Courtesy of Dr. Pinachyan

Take-home messages

NOACs are here to stay, to raise new questions & provide answers to unmet needs.

ESUS: potetial new indication for NOACs.

Stroke Medicine is rapidly changing (…and so should we)!