TY - JOUR
T1 - Periprocedural Intravenous Heparin During Endovascular Treatment for Ischemic Stroke
T2 - Results From the MR CLEAN Registry
AU - van de Graaf, Rob A.
AU - Chalos, Vicky
AU - van Es, Adriaan C. G. M.
AU - Emmer, Bart J.
AU - Nijeholt, Geert J. Lycklama A.
AU - van der Worp, H. Bart
AU - Schonewille, Wouter J.
AU - van der Lugt, Aad
AU - Dippel, Diederik W. J.
AU - Lingsma, Hester F.
AU - Roozenbeek, Bob
AU - Majoie, Charles
AU - Roos, Yvo
AU - van Oostenbrugge, Robert
AU - van Zwam, Wim
AU - Boiten, Jelis
AU - Vos, Jan Albert
AU - Jansen, Ivo
AU - Mulder, Maxim
AU - Goldhoorn, Robert-Jan
AU - Compagne, Kars
AU - Kappelhof, Manon
AU - Schonewille, Wouter
AU - Coutinho, Jonathan
AU - Wermer, Marieke
AU - van Walderveen, Marianne
AU - Staals, Julie
AU - Hofmeijer, Jeannette
AU - Martens, Jasper
AU - Nijeholt, Geert Lycklama A.
AU - Emmer, Bart
AU - de Bruijn, Sebastiaan
AU - van Dijk, Lukas
AU - Lo, Rob
AU - van Dijk, Ewoud
AU - Boogaarts, Hieronymus
AU - de Kort, Paul
AU - Peluso, Jo
AU - van den Berg, Jan
AU - van Hasselt, Boudewijn
AU - Aerden, Leo
AU - Dallinga, Rene
AU - Uyttenboogaart, Maarten
AU - Eshghi, Omid
AU - Schreuder, Tobien
AU - Heijboer, Roel
AU - Keizer, Koos
AU - Postma, Alida
AU - Groot, P.
AU - MR CLEAN Registry Investigators
N1 - Funding Information:
All authors are directly or indirectly involved as investigators for the MR CLEAN-MED (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; the Effect of Periprocedural Medication: Heparin, Antiplatelet Agents, Both or Neither; ISRCTN76741621). Dr Emmer is the recipient of compensation fees for review work from DEKRA and speaker fees from Novartis. Dr van der Worp has received speaker’s fees Boehringer Ingelheim and has served as a consultant to Boehringer Ingelheim. In addition, Dr van der Worp is the recipient of unrestricted grants from Dutch Heart Foundation and the European Union for the conduct of trials on acute treatment for stroke. Erasmus MC received compensation from Stryker, Medtronic, and Bracco Imaging Ltd for activities of Drs van der Lugt and Dippel as consultants. In addition, of Drs van der Lugt and Dippel are the recipients of unrestricted grants from Dutch Heart Foundation, Dutch Brain Foundation, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Science, AngioCare BV, Covidien/EV3, MEDAC Gmbh/LAMEPRO, Top Medical/ Concentric, Thrombolytic Science LLC, Stryker, Medtronic, and Penumbra, Inc for the conduct of trials on acute treatment for stroke. The other authors report no conflicts.
Funding Information:
The authors received no funding for this study. The MR CLEAN Registry is partially funded by unrestricted grants from Toegepast Wetenschappelijk Instituut voor Neuromodulatie, Twente University (TWIN), Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC.
Funding Information:
All authors are directly or indirectly involved as investigators for the MR CLEAN-MED (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; the Effect of Periprocedural Medication: Heparin, Antiplatelet Agents, Both or Neither; ISRCTN76741621). Dr Emmer is the recipient of compensation fees for review work from DEKRA and speaker fees from novartis. Dr van der Worp has received speaker's fees Boehringer Ingelheim and has served as a consultant to Boehringer Ingelheim. In addition, Dr van der Worp is the recipient of unrestricted grants from Dutch Heart Foundation and the European Union for the conduct of trials on acute treatment for stroke. Erasmus MC received compensation from Stryker, Medtronic, and Bracco Imaging Ltd for activities of Drs van der Lugt and Dippel as consultants. In addition, of Drs van der Lugt and Dippel are the recipients of unrestricted grants from Dutch Heart Foundation, Dutch Brain Foundation, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Science, AngioCare BV, Covidien/EV3, MEDAC Gmbh/LAMEPRO, Top Medical/Concentric, Thrombolytic Science LLC, Stryker, Medtronic, and Penumbra, Inc for the conduct of trials on acute treatment for stroke. The other authors report no conflicts.
Publisher Copyright:
© 2019 American Heart Association, Inc.
PY - 2019/8
Y1 - 2019/8
N2 - Background and Purpose- Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety.Methods- Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction >= 2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome.Results- One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%-94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87-1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89-1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65-1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66-1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01-1.13).Conclusions- Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.
AB - Background and Purpose- Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety.Methods- Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction >= 2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome.Results- One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%-94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87-1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89-1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65-1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66-1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01-1.13).Conclusions- Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.
KW - cerebral infarction
KW - heparin
KW - reperfusion
KW - stroke
KW - thrombectomy
KW - FOCAL CEREBRAL-ISCHEMIA
KW - REPERFUSION
KW - GUIDELINES
KW - PROUROKINASE
KW - PROACT
U2 - 10.1161/STROKEAHA.119.025329
DO - 10.1161/STROKEAHA.119.025329
M3 - Article
C2 - 31860411
SN - 0039-2499
VL - 50
SP - 2147
EP - 2155
JO - Stroke
JF - Stroke
IS - 8
ER -