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• W2037294308 abstract "HomeStrokeVol. 42, No. 6Anticoagulation in Patients With Stroke With Infective Endocarditis Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBAnticoagulation in Patients With Stroke With Infective EndocarditisThe Sword of Damocles Carlos A. Molina, MD, PhD and Magdy H. Selim, MD, PhD Carlos A. MolinaCarlos A. Molina From the Stroke Unit (C.A.M.), Department of Neurosciences, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain; and the Stroke Division (M.H.S.), Beth Israel Deaconess Medical Center, Boston, MA. Search for more papers by this author and Magdy H. SelimMagdy H. Selim From the Stroke Unit (C.A.M.), Department of Neurosciences, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain; and the Stroke Division (M.H.S.), Beth Israel Deaconess Medical Center, Boston, MA. Search for more papers by this author Originally published5 May 2011https://doi.org/10.1161/STROKEAHA.111.622423Stroke. 2011;42:1799–1800Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 Stroke complicating infective endocarditis (IE) poses a therapeutic dilemma, particularly in patients with prosthetic valves (PV). Most experts recommend against the use of anticoagulation because of increased risk of intracerebral hemorrhage (ICH). Some worry that stopping anticoagulation increases the risk of clot formation on the PV and further embolization. Brain embolization in the setting of IE may result in a wide spectrum of clinical scenarios with different risk/benefit profiles to anticoagulation. Dr Rasmussen, a cardiologist, states that the potential harmful effect of anticoagulation is overestimated and that the beneficial effect of ongoing anticoagulation to prevent early recurrent stroke counterbalances the low risk of ICH. He, therefore, recommends in our case switching from warfarin to heparin due to the likelihood of urgent surgery. Conversely, Dr Sila, a neurologist, argues that anticoagulation should not be initiated and patients already on anticoagulantion should have it stopped as soon as a diagnosis of IE is suspected given the low rate of early recurrent stroke and high incidence of early ICH and hemorrhagic transformation (HT) in patients with stroke with Staphylococcus aureus IE. These diametrically opposed perspectives by our experts may reflect not only divergent approaches to different stages in the natural history of IE, but also “consultation bias” with a broader spectrum of IE seen by cardiologists, including less severe or even neurologically asymptomatic patients and more selected, often severely affected, patients seen by neurologists.The beneficial or deleterious effect of anticoagulation in patients with IE is determined by a multitude of clinical, bacteriologic, radiological, and echocardiographic variables that may tilt the balance of the risk toward early recurrent stroke or ICH. These include native versus PV IE, size of the vegetation and its location on the mitral or aortic valve, virulence of the infective organism, size of the infarct(s), and presence of HT or mycotic aneurysms. The evidence against anticoagulation is largely anecdotal and based on retrospective nonrandomized studies reported in the late 1990s, including mainly severe patients with clinical evidence of IE, showing an increased risk of hemorrhagic complications and mortality especially in those patients on anticoagulants.1 On the other hand, more recent prospective studies show no association between anticoagulation and ICH. However, these studies were nonrandomized and included less severe patients with a high rate of native valve IE diagnosed at an early stage, which may have resulted in a lower incidence of ICH.Rapid institution of effective antibiotic therapy represents the cornerstone of medical treatment of IE to reduce the mortality and morbidity from embolic complications and heart failure. Although the risk of early recurrent stroke is 1% to 3% in the overall IE population, it is certainly higher in patients with PV. Antibiotic therapy may reduce vegetation size; however, its efficacy in decreasing further embolism in patients with PV endocarditis may be limited. Although there is little evidence that anticoagulation reduces the risk of embolization in patients with native valve, the data are conflicting for PV IE. Our protagonists agree that surgery, when warranted, should be performed as soon as possible because the risk of complications is comparable to those operated 2 to 3 weeks later; we concur.The decision of anticoagulation before valve replacement is a real Damocles' sword over our patient. Risk stratification and decision-making should be based on the individual risk balance of potentially devastating HT and further embolic ischemic stroke because S. aureus is the most aggressive form of IE in terms of both ischemic and hemorrhagic stroke risk. Potential mechanisms for ICH in patients with IE include HT of the ischemic infarct, rupture of mycotic aneurysms, or erosion of the septic arteritic vessels, the former being the most common. Although spontaneous HT after reperfusion is part of the natural history of cardioembolic stroke, symptomatic and in some cases devastating HT is more frequently seen in patients with IE, especially when S. aureus infection and anticoagulation concur. The risk of HT mainly depends on the size of the infarcted tissue. Therefore, it seems reasonable to withdraw anticoagulation, at least temporarily, in patients with large territorial infarctions. However, patients with smaller infarcts are also at risk of ICH. Numerous cerebral microbleeds seen on T2*-weighted MRI are highly prevalent in patients with IE, which may reflect a subacute microvascular inflammation that heralds mycotic aneurysms.2 Therefore, emergent MRI evaluation, including diffusion-weighted imaging, MR angiography, and T2*-weighted sequences, may help to identify patients with IE at risk of hemorrhagic complications. On the other hand, extensive echocardiographic evaluation may help to identify those at risk of early recurrent embolism who require continuing anticoagulants. Large (>10 mm) and mobile vegetations have been associated with multiple brain and spleen embolisms.We agree that the risk of devastating ICH due to anticoagulation after IE-related stroke, particularly when small, may be overestimated; however, it is not nil. Therefore, we support a more conservative approach unless there is overwhelming evidence for high risk of recurrent embolization. There is certainly a need for randomized studies in patients with IE with stroke to determine the risk/benefit of anticoagulation using multimodal MRI and echocardiography for patient selection and stratification, but is this ever likely to occur?DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. This article is Part 3 in a 3-part series. Parts 1 and 2 appear on pages 1795 and 1797, respectively.Correspondence to Carlos A. Molina, MD, PhD, Stroke Unit, Department of Neurosciences, Hospital Vall d'Hebron-Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain. E-mail [email protected]net; and Magdy H. Selim, MD, PhD, Beth Israel Deaconess Medical Center, Stroke Division, 330 Brookline Avenue, Palmer 127, Boston, MA 02215. E-mail [email protected]harvard.eduReferences1. Tornos P, Almirante B, Mirabet S, Permanyer G, Pahissa A, Soler-Soler J. Infective endocarditis due to Staphylococcus aureus. Deleterious effect of anticoagulant therapy. Arch Intern Med. 1999; 159: 473–475CrossrefMedlineGoogle Scholar2. Klein I, Iung B, Labreuche J, Hess A, Wolff M, Messika-Zeitoun D, Lavallée P, Laissy JP, Leport C, Duval X; IMAGE Study Group. Cerebral microbleeds are frequent in infective endocarditis: a case–control study. Stroke. 2009; 40: 3461–3465LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By L. Furie K, Yaghi S and Khan M (2022) Secondary Prevention of Cardioembolic Stroke Stroke, 10.1016/B978-0-323-69424-7.00064-8, (932-943.e4), . Østergaard L, Andersson N, Kristensen S, Dahl A, Bundgaard H, Iversen K, Eske-Bruun N, Gislason G, Torp-Pedersen C, Valeur N, Køber L and Fosbøl E (2019) Risk of stroke subsequent to infective endocarditis: A nationwide study, American Heart Journal, 10.1016/j.ahj.2019.03.010, 212, (144-151), Online publication date: 1-Jun-2019. Taranova M, Androsova T, Kozlovskaya L, Strizhakov L, Lebedeva M, Milovanova L and Mukhin N Predictive value of thromboembolic complications in infective endocarditis, the possibility of prevention., Clinical Medicine (Russian Journal), 10.18821/0023-2149-2018-96-2-129-136, 96:2, (129-136) Kamel H and Healey J (2017) Cardioembolic Stroke, Circulation Research, 120:3, (514-526), Online publication date: 3-Feb-2017. Tuta S (2016) Pharmacological Measures for the Treatment and Prevention of Stroke: The Choice of Initial Therapy Arterial Revascularization of the Head and Neck, 10.1007/978-3-319-34193-4_8, (191-210), . Furie K and Khan M (2016) Secondary Prevention of Cardioembolic Stroke Stroke, 10.1016/B978-0-323-29544-4.00062-1, (1014-1029.e4), . Liang H, Xu Z, Feng Q and Ma L (2014) Recurrent cerebral embolism secondary to esophageal and atrial foreign body complicated by infective endocarditis, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2014.08.012, 148:5, (e213-e214), Online publication date: 1-Nov-2014. Williams L and Brosch J (2014) Neurologic Manifestations of Infective Endocarditis Aminoff's Neurology and General Medicine, 10.1016/B978-0-12-407710-2.00006-0, (99-117), . Lee S, Oh S, Lim D, Hong S, Choi R and Park J (2014) Usefulness of Anticoagulant Therapy in the Prevention of Embolic Complications in Patients with Acute Infective Endocarditis, BioMed Research International, 10.1155/2014/254187, 2014, (1-7), . Klein C, Gørtz S, Wohlfahrt J, Nørgaard Munch T, Melbye M, Bundgaard H and Iversen K (2019) Increased Risk of Ischemic Stroke After Treatment of Infective Endocarditis: A Danish, Nationwide, Propensity Score–Matched Cohort Study, Clinical Infectious Diseases, 10.1093/cid/ciz320 June 2011Vol 42, Issue 6 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.622423PMID: 21546479 Manuscript receivedApril 4, 2011Manuscript acceptedApril 6, 2011Originally publishedMay 5, 2011 KeywordsendocarditisanticoagulationPDF download Advertisement SubjectsAnticoagulantsTreatment" @default.
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