Evidence-based Treatment for a Patient with Ischemic Stroke Accompanied by Hypertension and Atrial Fibrillation_Chinese Journal of Evidence-Based Medicine

Authors：

 LIU Yin ¹ , WU Hongmei ²

1. Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China2. Department of Geriatric, West China Hospital, Sichuan University, Chengdu 610041, China;

Corresponding author：

LIU Yin, Email: liuyin61@163.com

Keywords：

Ischemic Stroke; Hypertension; Atrial fibrillation; Anticoagulants; Evidence-based treatment

DOI：

10.7507/1672-2531.20080012

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective 　To formulate an evidence-based treatment plan for a patient with ischemic stroke accompanied by hypertension and atrial fibrillation.
Methods　 We searched The Cochrane Library (Issue 4, 2006), SUMsearch (January 1980 to December 2006) and PubMed (January 1980 to December 2006) to identify randomized controlled trials (RCTs), systematic reviews (SRs) and meta-analyses about the efficacy and safety of anticoagulant therapy for ischemic stroke coupled with atrial fibrillation, and blood pressure lowering therapy for ischemic stroke coupled with hypertension. We evaluated the validity, reliability and feasibility of each study to identify the current best evidence.
Results　 Four guidelines, 3 SRs and 6 RCTs were included. The evidence showed that low-intensity anticoagulant therapy was safe and effective for this patient, and that rapid blood pressure lowering therapy was not suitable for acute ischemic stroke. According to the current evidence, as well as the patient’s clinical condition and preference, low-intensity warfarin was given with a target INR (international normalized ratio) of 2.0. During convalescence, he was given oral fosinopril and indapamide. His symptoms were relieved after two weeks of treatment, and follow-up at one month indicated that this plan was suitable for the patient.
Conclusions　 Anticoagulant therapy is still preferred for acute ischemic stroke accompanied by hypertension and atrial fibrillation. The current evidence suggests that warfarin is superior to other anticoagulants. The target INR should be adjusted individually, especially in old patients. The maintenance of a low INR level, if necessary, could maximise utility and minimise the risk of hemorrhage. Aspirin is recommended when anticoagulants cannot be tolerated. Intensive blood pressure lowering therapy is not reasonable for patients with acute ischemic stroke. Antihypertensive drugs like ACEI and low-dose diuretics may be chosen during convalescence.

Citation： LIU Yin,WU Hongmei. Evidence-based Treatment for a Patient with Ischemic Stroke Accompanied by Hypertension and Atrial Fibrillation. Chinese Journal of Evidence-Based Medicine, 2008, 08(1): 51-54. doi: 10.7507/1672-2531.20080012 Copy

1.	Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet, 1993, 342(8882): 1255-1262.
2.	Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6?105 individuals with previous stroke or transient ischaemic attack. Lancet, 2001, 358(9287): 1033-1041.
3.	Post-stroke antihypertensive treatment study. A preliminary result. PATS Collaborating Group. Chin Med J (Engl), 1995, 108(9): 710-717.
4.	Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke, 2006, 37(2): 577-617.
5.	Saxena R, Koudstaal P. Anticoagulants versus antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev, 2004, (4): CD000187.
6.	Morocutti C, Amabile G, Fattapposta F, et al. Indobufen versus warfarin in the secondary prevention of major vascular events in nonrheumatic atrial fibrillation. SIFA (Studio Italiano Fibrillazione Atriale) Investigators. Stroke, 1997, 28(5): 1015-1021.
7.	Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet, 2000, 355(9211): 1205-1210.
8.	Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation, 2006, 114(7): e257-354.
9.	Yamaguchi T. Optimal intensity of warfarin therapy for secondary prevention of stroke in patients with nonvalvular atrial fibrillation : a multicenter, prospective, randomized trial. Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study Group. Stroke, 2000, 31(4): 817-821.
10.	Interventions for deliberately altering blood pressure in acute stroke. Blood pressure in Acute Stroke Collaboration (BASC). Cochrane Database Syst Rev, 2000, (2): CD000039.
11.	Adams H, Adams R, Del Zoppo G, et al. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke, 2005, 36(4): 916-923.
12.	Hack W, Kaste M, Bogousslavsky J, et al. European Stroke Initiative Recommendations for Stroke Management-update 2003. Cerebrovasc Dis, 2003, 16(4): 311-337.

1. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet, 1993, 342(8882): 1255-1262.
2. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6?105 individuals with previous stroke or transient ischaemic attack. Lancet, 2001, 358(9287): 1033-1041.
3. Post-stroke antihypertensive treatment study. A preliminary result. PATS Collaborating Group. Chin Med J (Engl), 1995, 108(9): 710-717.
4. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke, 2006, 37(2): 577-617.
5. Saxena R, Koudstaal P. Anticoagulants versus antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev, 2004, (4): CD000187.
6. Morocutti C, Amabile G, Fattapposta F, et al. Indobufen versus warfarin in the secondary prevention of major vascular events in nonrheumatic atrial fibrillation. SIFA (Studio Italiano Fibrillazione Atriale) Investigators. Stroke, 1997, 28(5): 1015-1021.
7. Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet, 2000, 355(9211): 1205-1210.
8. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation, 2006, 114(7): e257-354.
9. Yamaguchi T. Optimal intensity of warfarin therapy for secondary prevention of stroke in patients with nonvalvular atrial fibrillation : a multicenter, prospective, randomized trial. Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study Group. Stroke, 2000, 31(4): 817-821.
10. Interventions for deliberately altering blood pressure in acute stroke. Blood pressure in Acute Stroke Collaboration (BASC). Cochrane Database Syst Rev, 2000, (2): CD000039.
11. Adams H, Adams R, Del Zoppo G, et al. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke, 2005, 36(4): 916-923.
12. Hack W, Kaste M, Bogousslavsky J, et al. European Stroke Initiative Recommendations for Stroke Management-update 2003. Cerebrovasc Dis, 2003, 16(4): 311-337.

Chinese Journal of Evidence-Based Medicine

Evidence-based Treatment for a Patient with Ischemic Stroke Accompanied by Hypertension and Atrial Fibrillation

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content