A Retrospective Case Series Study On The Clinical Characteristics And Anticoagulation Therapy Of Patients With Cardiogenic Cerebral Embolism

Objective: This study was initiated to analyze the general clinical data of patients with cardiogenic cerebral embolism, and study their clinical characteristics and medication treatments. Through the anticoagulation therapy of patients with nonvalvular atrial fibrillation, we tried to investigate factors related to optimal maintenance dose of warfarin, and explore their stroke recurrence rate, hemorrhagic transformation rate, etc.Method: 208 patients with cardiogenic cerebral embolism from the Second Affiliated Hospital of Soochow University during 2012.01-2013.12 and 36 outpatients from the internal Medicine-Neurology with nonvalvular atrial fibrillation who were accepted warfarin for anticoagulation therapy and primary prevention were enrolled, and the follow-up period was one year. Firstly, according to whether death in three months after this stroke, 208 patients were divided into the death group and the survival group, then we compared their baseline data respectively and analyzed risk factors related to death. Secondly, 164 nonvalvular atrial fibrillation patients were divided into anticoagulation group and antiplatelet group according to the different treatments, and the prognosis of patients were compared between the two groups. Finally, we analyzed the general clinical data of 70 warfarin anticoagulant therapy patients, and they were divided into different groups according to the prevention grade, age, INR control level and bleeding or not, then we compared each group and studied factors related to the stable warfarin dose.Result: The most common etiology of cardiogenic cerebral embolism was nonvalvular atrial fibrillation. Judging from the imaging, left hemisphere(97 cases, 46.6%), confluent and additional lesions(93 cases, 44.7%) and a single large lesion(76 cases, 36.5%) were common in 208 patients. Considering the OCSP classification, total anterior circulation infarcts(121 cases, 58.2%)was the most common. The mortality rate of cardiogenic cerebral embolism patients was relatively high(15.9%), and bilateral cerebral embolism(OR=2.570, P=0.014), a single large lesion(OR=0.433, P=0.005) and high initial NIHSS scale(OR=1.179, P=0.000) were independent risk factors for death of cardiogenic cerebral embolism patients. We could see in the 164 cerebral embolism patients caused by nonvalvular atrial fibrillation that proportion for anticoagulation therapy was relatively low(20.7%). The incidence rate of extracranial hemorrhage in anticoagulation group was higher than in antiplatelet group(P<0.05), and there was no statistically significant difference in the incidence rate of intracranial hemorrhage, the recurrence rate of cerebral infarction and the mortality rate in one year. Among 70 anticoagulation therapy patients, compared with the secondary prevention patients, primary prevention patients were much younger, and had lower initial NIHSS scale, smaller risk of anticoagulation hemorrhage, better long term prognosis(P<0.05). The initial dose of warfarin in secondary prevention patients was lower, but warfarin withdrawal rate within one year was significantly higher than primary prevention patients(P<0.05). Comparison of patients who were 65 years old or more, the initial and stable warfarin dose in less than 65 years old group were obviously higher(P<0.05), and the risk of anticoagulation hemorrhage and stroke caused by atrial fibrillation were smaller(P<0.05), but there was no statistically significant difference in the incidence rate of hemorrhage, the recurrence rate of cerebral infarction and the withdrawal rate of warfarin between the two groups. There was no statistically significant difference in the recurrence rate of cerebral infarction and the incidence rate of intracranial or extracranial hemorrhage between the low intensity anticoagulation group(INR 1.5~2.0) and the traditional intensity anticoagulation group(INR 2.1~3.0). Compared with the non hemorrhage group, the initial NIHSS scale was obviously higher(P=0.026) and the initial INR was lower(P=0.003) in the hemorrhage group, but the stable INR was no statistically significant difference between the two groups. There was a negative correlation between the stable warfarin dose and age, and a positive correlation between the stable and the initial warfarin dose, but age and the initial warfarin dose both could not explain the stable warfarin dose variation.Conclusion: 1. The most common etiology of cardiogenic cerebral embolism was nonvalvular atrial fibrillation. The rate of hemorrhagic transformation after cerebral embolism and the mortality rate were high. Bilateral cerebral embolism, a single large lesion and high initial NIHSS scale were independent risk factors for death of cardiogenic cerebral embolism patients. 2. People who were younger, milder symptoms of admission and had the anticoagulation treatment history and smaller risk of hemorrhagic transformation were easy to accept anticoagulation therapy. The incidence rate of extracranial hemorrhage in anticoagulation group was higher than in antiplatelet group, there was no statistically significant difference in the incidence rate of intracranial hemorrhage, the recurrence rate of cerebral infarction and the mortality rate. 3. Compared with the secondary prevention patients, the primary prevention patients who taken the warfarin had slightly lighter age and better compliance. There was no statistically significant difference in reducing the incidence of stroke and the risk of hemorrhage between the low intensity anticoagulation group(INR 1.5~2.0) and the traditional intensity anticoagulation group(INR 2.1~3.0). The initial and stable warfarin dose were both higher in younger patients, but the risk of stroke and hemorrhage were lower.