Current perspectives on cardioembolic ischemic stroke in very old patients

Figures & data

Figure 1 Pathological specimen showing a hemorrhagic cerebral infarction of cardioembolic origin in the vascular superficial distribution territory of the posterior cerebral artery.

Table 1 Clinical characteristics of cardioembolic infarction

Sudden onset of focal neurological deficit Maximum focal neurological dysfunction at onset of clinical symptoms Stroke onset while awake Onset after a Valsalva maneuver (paradoxical embolism) Presence of a non-lacunar clinical syndrome Wernicke aphasia Isolated aphasia Spectacular shrinking deficit syndrome Concomitant peripheral vascular embolism Simultaneous cerebral infarcts in different territories on neuroimaging studies

Table 2 Demographic variables, cerebrovascular risk factors, neuroimaging findings, and outcome in the first-ever stroke according to age (“Sagrat Cor Hospital of Barcelona Stroke Registry” for the period 1986–2004)

Variables	Age of the patients		P-value
	≥85 years (n=577)	≤84 years (n=2,413)
Age (years), mean (SD)	88.55 (3.2)	70.95 (11.1)	0.0000
Sex			0.0000
Males	180 (31.2)	1,267 (52.5)
Females	397 (68.8)	1,146 (47.5)
Hypertension	293 (50.8)	1.344 (55.7)	0.033
Diabetes	88 (15.3)	3,537 (22.3)	0.000
Atrial fibrillation	212 (36.7)	543 (22.5)	0.000
Ischemic heart disease	76 (13.2)	341 (14.1)	0.500
Heart failure	60 (10.4)	71 (2.9)	0.000
Heart valve disease	29 (5.0)	146 (6.1)	0.346
TIA	63 (10.9)	282 (11.7)	0.604
Chronic bronchitis	55 (9.5)	177 (7.3)	0.076
Peripheral vascular disease	29 (5.0)	184 (7.6)	0.029
Heavy smoking	8 (1.4)	292 (12.1)	0.000
(>20 cigarettes/day)
Dyslipidemia	65 (11.3)	498 (20.6)	0.000
Headache	48 (8.3)	415 (17.2)	0.000
Nausea, vomiting	41 (7.1)	246 (10.2)	0.024
Altered consciousness	165 (28.6)	364 (15.1)	0.000
Motor impairment	444 (76.9)	1,658 (68.7)	0.000
Speech disturbance	321 (55.6)	1,185 (49.1)	0.005
Stroke subtypes			0.000
TIA	79 (13.7)	423 (17.5)
Atherothrombotic	121 (21.0)	444 (18.4)
Lacunar	82 (14.2)	484 (20.1)
Cardioembolic	164 (28.4)	411 (17.0)
Unknown cause	53 (9.2)	227 (9.4)
Infrequent etiology	4 (0.7)	92 (3.8)
Intracerebral hemorrhage	58 (10.1)	276 (11.4)
Subarachnoid hemorrhage	5 (0.9)	38 (1.6)
Subdural hematoma	11 (1.9)	17 (0.7)
Epidural hematoma	0	1 (0.0)
Middle cerebral artery topography	266 (46.1)	1,004 (41.6)	0.05
Echocardiography	250 (43.3)	1,030 (42.7)	0.779
MRI	72 (12.5)	756 (31.3)	0.000
Neurologic complications	74 (12.5)	236 (9.8)	0.031
Respiratory complications	86 (14.9)	150 (6.2)	0.009
Urinary complications	68 (11.8)	159 (6.6)	0.000
Infectious complications	114 (19.8)	241 (10.1)	0.000
Symptom-free at discharge	154 (26.7)	951 (39.4)	0.000
In-hospital death	126 (21.8)	225 (9.3)	0.000
Transfer to convalescent/rehabilitation units	78 (13.5)	238 (9.9)	0.010
Length of stay (days), median (interquartile range)	12 (8–20)	11 (7–19)	0.184
Prolonged hospital stay >12 days	266 (46.1)	1,030 (42.7)	0.137

Note: Data are expressed as numbers and percentages in parentheses unless otherwise stated.

Abbreviations: SD, standard deviation; TIA, transient ischemic attack; MRI, magnetic resonance imaging.

Table 3 Pharmacological characteristics of new anticoagulant drugs

Dabigatran

Direct thrombin inhibitor

Relatively short half-life (12–17 hours), rapid onset of action (2–3 hours), few drug interactions, no food interaction 80% renal elimination; therefore, it should not be used in patients with renal failure (creatinine clearance <15 mL/min)

Oral route, every 12 hours, and has been shown to be equally effective and more safe (less likely to cause hemorrhage) than warfarin when given at a dose of 110 mg/12 hours, and more effective and equally safe as warfarin when administered at a dose of 150 mg/12 hours

Rivaroxaban

Direct factor Xa inhibitor

Short half-life (5–9 hours), rapid onset of action (2–3 hours), few drug interactions, no food interaction

Low renal elimination (36%), so that it can be administered to patients with renal failure. Predictable pharmacokinetics, it can be administered at fixed doses, and monitorization of drug levels is not required. Similar efficacy as warfarin but more safe

Oral route at doses of 20 mg/24 hours

Apixaban

Direct factor Xa inhibitor

Oral route at doses of 5 mg/12 hours

Short half-life (8–15 hours), rapid onset of action (3–4 hours), predictable pharmacokinetics, it can be administered at fixed doses, and monitorization of drug levels is not required

Low renal elimination (25%), so that it can be administered to patients with renal failure without dose modification, contraindicated in the presence of creatinine clearance <15 mL/min

More effective and safe than warfarin for the prevention of cardioembolism in patients with non-valvular atrial fibrillation