Expert Opinion on the Use of Novel Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation for the Primary Care Setting in India: A Literature Review.

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia encountered in clinical practice, is linked with substantial morbidity and mortality due to accompanying risk of stroke and thromboembolism. Patients with AF are at a five-fold higher risk of suffering from a stroke. Anticoagulation therapy, with either vitamin K antagonists or novel oral anticoagulants (NOACs), is a standard approach to reduce the risk. Consultant physicians (CPs) in India are the primary point of contact for the majority of patients before they approach a specialist. The CPs may face challenges in screening and diagnosing AF patients. The apprehensions associated with managing AF patients with anticoagulants, further add to the challenges of a CP. This review aimed to identify the key decision points for the CPs to diagnose AF and initiate anticoagulation in patients with non-valvular AF (NVAF) and bring to the table a simplified recommendation supported by expert opinion and guidelines for stroke prevention in NVAF patients.

New Onset Refractory Status Epilepticus as a Manifestation of Tuberculosis of the Central Nervous System.

A 28-year-old male presented to us with new onset refractory status epilepticus. Prior to his seizures, he had a history of fever, headache and blurring of vision, for which he was admitted elsewhere. No cause was found; he was treated symptomatically and was discharged as his symptoms had abated. Post-discharge, he started having multiple seizures. Neuro-imaging suggested encephalitis. He progressed to status epilepticus and was referred to our center. We intensified the anti-epileptic medications but owing to no response, he had to be put under coma with thiopental, yet the seizures persisted. Workup for the etiology of his seizures was negative except for CSF TB-PCR (Gene Xpert) being positive and hence anti-tuberculous therapy was initiated. By this time, he developed rhabdomyolysis, and thereafter renal failure with dyselectrolytemia, and thus there was a plan to initiate dialysis. But before this could be done, he succumbed to a cardiac arrest secondary to ventricular tachyarrhythmias. We believe this to be the first reported case of new onset refractory status epilepticus secondary to tuberculosis of the central nervous system.

The Indian consensus guidance on stroke prevention in atrial fibrillation: An emphasis on practical use of nonvitamin K oral anticoagulants.

The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs.

Effects of thrombolysis for acute stroke in patients with pre-existing disability.

BACKGROUND: Thrombolysis for acute stroke is beneficial in selected patients. Because clinical trials generally exclude patients with pre-existing disability, this subgroup of patients has not been studied. We examined the outcomes after thrombolysis of patients with and without disability before their stroke. METHODS: We prospectively followed 112 consecutive patients with acute ischemic stroke who were given intravenous thrombolysis treatment according to published protocols. Three-month outcomes of the patients with pre-existing disability (defined as a prestroke score of 2 or more on the modified Rankin scale [MRS]) were compared with those of patients without pre-existing disability (defined as a prestroke MRS score of 0 or 1) and with those of 168 patients similarly treated in the National Institute of Neurological Disorders and Stroke trial. RESULTS: At 3 months after the stroke, patients with pre-existing disability (21% of the 112) had a higher mortality rate than those without (33% v. 14%) (odds ratio 3.2, 95% confidence interval 1.0-10.1) and worse function (median MRS score 3 v. 2, p = 0.03). However, there was little difference between the 2 groups in neurologic impairment among the survivors (median score on the National Institutes of Health stroke scale 4 v. 2, p = 0.41) or in the total proportion of those with an MRS score of 0 or 1 or, for those with a prestroke score greater than 1, a return to the prestroke score (42% v. 41%, p = 0.87). INTERPRETATION: Although the true effectiveness of thrombolysis for acute stroke in patients with pre-existing disability is not known, treated patients appear able to return to their prestroke level of function as often as patients without pre-existing disability, despite a significantly higher mortality rate.

Extending tissue plasminogen activator use to community and rural stroke patients.

BACKGROUND AND PURPOSE: Guidelines for intravenous tissue plasminogen activator (tPA) use in stroke emphasize the importance of limiting its use to facilities with imaging capabilities and stroke expertise. This prospective case series set out to evaluate the safety of tPA use in patients referred from rural communities to a tertiary center. METHODS: Prospective data of 82 consecutive patients treated with tPA in London, Ontario, were reviewed. RESULTS: Twenty-three patients were transferred to London from a rural hospital (non-London patients); 49 were first evaluated in a London emergency room (London ER); and 10 were inpatients in a London hospital at the time of stroke onset. Mean transfer time and distance to London for non-London patients were 89 minutes and 41 miles. Although symptom onset to London ER times were longer for non-London than for London ER patients (123 versus 53 minutes), the door to needle times were significantly shorter for the former (49 versus 95 minutes, P<0.005). Imaging to needle times were longer for London inpatients compared with London ER patients (55 versus 36 minutes, P=0.16). The proportion of patients with >4-point improvement on the NIH Stroke Scale or cure at 24 hours was 57%, with no difference among groups (P=0.46). The overall symptomatic hemorrhage rate at 36 hours was 2%. No significant differences in outcomes were observed at 3 months. CONCLUSIONS: This prospective study suggests that it is feasible and safe to treat rural patients referred to a tertiary care center with tPA, thus extending the benefits of thrombolysis for acute stroke to a wider population.