Heart Care Info - Heart Disease Prevention & Treatment

Anticoagulation Should Not Be Used in Most Patients With Stroke With Infective Endocarditis

C Sila - Stroke, 2011 - Am Heart Assoc1. Correspondence to Cathy Sila, MD, George M. Humphrey II Professor of Neurology, Director, Stroke & Cerebrovascular Center, Neurological Institute, University HospitalsCase Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid ...

One of the most worrisome consults to the stroke service is the patient with neurological symptoms in the setting of infective endocarditis (IE). Stroke is the main neurological complication of IE and in 50% to 75% is the presenting feature. The most effective strategy for the prevention of a first or recurrent stroke is the prompt institution of appropriate antibiotic therapy, which reduces the risk to 1% to 3% within the first week.1 Ischemic stroke is 3-fold more common than hemorrhagic stroke. Embolic patterns are seen on diffusion-weighted MR in 92% of patients with stroke or encephalopathy. Initiating anticoagulation may seem reasonable to prevent embolization of infected or bland platelet–fibrin valvular vegetations—perhaps enhanced in the presence of antiphospholipid antibodies—and it is the standard of care for most cardioembolic stroke; however, the stroke risk is similar in the presence or absence of anticoagulants at onset of IE. The most compelling reason to avoid anticoagulation in Staphylococcus aureus IE is the predominance of early intracranial hemorrhage and hemorrhagic conversion of ischemic stroke.1–3 In Tornos' study of IE from S. aureus, the risk of stroke with native valve endocarditis was 22%; all were ischemic at onset and 57% became hemorrhagic in the absence of anticoagulation. Patients with prosthetic valve endocarditis were converted from oral anticoagulants to intravenous heparin on admission. Their risk of stroke was substantially higher at 52%; half were hemorrhagic at onset and the remainder converted within 48 to 72 hours. In Heiro's study, the 90-day ...