(Stroke. 1995;26:63-69.)
© 1995 American Heart Association, Inc.
Articles |
Monitoring Combined Antithrombotic Treatments in Patients With Prosthetic Heart Valves Using Transcranial Doppler and Coagulation Markers
From the Departments of Neurology (M.S., F.R.) and Internal Medicine, Laboratory for Thrombosis Research (J.H.B.), University of Bern, Inselspital, Bern, Switzerland.
Correspondence to Matthias Sturzenegger, MD, Department of Neurology, University of Bern, Inselspital, CH-3010 Bern, Switzerland.
Background and Purpose The combined use of coumarin and low-dose aspirin appears to reduce the risk of systemic embolism at a low risk of bleeding. The remaining incidence of embolism of approximately 2%/y is still high. Methods for real-time detection of embolic events have not been used thus far to monitor the efficacy of therapeutic strategies. They might permit individually tailored, effective treatments.
Methods The frequency of embolic signals in both middle cerebral arteries was monitored using a two-channel 2-MHz transcranial Doppler system. We examined five patients with mechanical prosthetic heart valves suffering from recurrent cerebral ischemic symptoms despite adequate anticoagulant therapy (international normalized ratio, 3.0 to 4.3). Measurements were performed on coumarin alone (four baseline values) and subsequent to the addition of intravenous (500 mg bolus) and oral (100 mg/d for 10 days) aspirin or intravenous (5000 IU bolus) heparin. The prothrombotic markers thrombin–antithrombin III complex, fibrinopeptide A, D-dimer, and platelet ß-thromboglobulin were measured simultaneously.
Results None of the combined drug regimens led to a significant reduction of the emboli count. The values of thrombin–antithrombin III complex, fibrinopeptide A, and D-dimer were already within normal limits with coumarin alone. The ß-thromboglobulin levels, however, were increased, and additional aspirin or heparin did not reduce them. There was no correlation between the emboli count and the prothrombotic markers or between the prothrombotic markers and the different drug regimens.
Conclusions The rate of cerebral emboli measured with transcranial Doppler in the group of high-risk patients studied was not influenced by additional antiplatelet therapy. The emboli are likely to be composed at least in part of platelets, and their generation seems not dependent on thrombin or cyclooxygenase. There is an apparent discrepancy between the unchanged rate of emboli during Doppler monitoring found in this and other studies and the partial efficacy of combined treatment with coumarin and aspirin in clinical long-term studies. This may be explained by differences in the composition or size of the emboli.
Key Words: anticoagulants • antiplatelet agents • heart valve prosthesis • thromboembolism • ultrasonics
This article has been cited by other articles:
 |
|
 |
|
  A. King and H. S. Markus Doppler Embolic Signals in Cerebrovascular Disease and Prediction of Stroke Risk: A Systematic Review and Meta-Analysis * Supplemental Online References Stroke, December 1, 2009; 40(12): 3711 - 3717. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Skjelland, A. Michelsen, F. Brosstad, J. L. Svennevig, R. Brucher, and D. Russell Solid Cerebral Microemboli and Cerebrovascular Symptoms in Patients With Prosthetic Heart Valves Stroke, April 1, 2008; 39(4): 1159 - 1164. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Guerrieri Wolf, B. P. Choudhary, Y. Abu-Omar, and D. P. Taggart Solid and gaseous cerebral microembolization after biologic and mechanical aortic valve replacement: Investigation with multirange and multifrequency transcranial Doppler ultrasound J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 512 - 520. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Dittrich and E. B. Ringelstein Occurrence and Clinical Impact of Microembolic Signals During or After Cardiosurgical Procedures Stroke, February 1, 2008; 39(2): 503 - 511. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 U. Junghans and M. Siebler Cerebral Microembolism Is Blocked by Tirofiban, a Selective Nonpeptide Platelet Glycoprotein IIb/IIIa Receptor Antagonist Circulation, June 3, 2003; 107(21): 2717 - 2721. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Laas, S. Kseibi, M. Perthel, A. Klingbeil, L'E. El-Ayoubi, and A. Alken Impact of high intensity transient signals on the choice of mechanical aortic valve substitutes Eur. J. Cardiothorac. Surg., January 1, 2003; 23(1): 93 - 96. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Russell and R. Brucher Online Automatic Discrimination Between Solid and Gaseous Cerebral Microemboli With the First Multifrequency Transcranial Doppler Stroke, August 1, 2002; 33(8): 1975 - 1980. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. W. Baumgartner, A. Frick, C. Kremer, E. Oechslin, E. Russi, J. Turina, and D. Georgiadis Microembolic signal counts increase during hyperbaric exposure in patients with prosthetic heart valves J. Thorac. Cardiovasc. Surg., December 1, 2001; 122(6): 1142 - 1146. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Kamath, A.D. Blann, and G.Y.H. Lip Platelet activation: assessment and quantification Eur. Heart J., September 1, 2001; 22(17): 1561 - 1571. [PDF]
|
|
|
|
|
|
C. R. Wilhelm, J. Ristich, L. E. Knepper, R. Holubkov, S. R. Wisniewski, R. L. Kormos, and W. R. Wagner Measurement of Hemostatic Indexes in Conjunction With Transcranial Doppler Sonography in Patients With Ventricular Assist Devices Stroke, December 1, 1999; 30(12): 2554 - 2561. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Goertler, M. Baeumer, R. Kross, T. Blaser, G. Lutze, S. Jost, and C.-W. Wallesch Rapid Decline of Cerebral Microemboli of Arterial Origin After Intravenous Acetylsalicylic Acid Stroke, January 1, 1999; 30(1): 66 - 69. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Geiser, M. Sturzenegger, U. Genewein, A. Haeberli, and J. H. Beer Mechanisms of Cerebrovascular Events as Assessed by Procoagulant Activity, Cerebral Microemboli, and Platelet Microparticles in Patients With Prosthetic Heart Valves Stroke, September 1, 1998; 29(9): 1770 - 1777. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Deklunder, M. Roussel, J.-L. Lecroart, A. Prat, and C. Gautier Microemboli in Cerebral Circulation and Alteration of Cognitive Abilities in Patients With Mechanical Prosthetic Heart Valves Stroke, September 1, 1998; 29(9): 1821 - 1826. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
U. Sliwka and D. Georgiadis Clinical Correlations of Doppler Microembolic Signals in Patients With Prosthetic Cardiac Valves : Analysis of 580 Cases Stroke, January 1, 1998; 29(1): 140 - 143. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. W. Droste, T. Hansberg, V. Kemeny, D. Hammel, G. Schulte-Altedorneburg, D. G. Nabavi, M. Kaps, H. H. Scheld, and E. B. Ringelstein Oxygen Inhalation Can Differentiate Gaseous From Nongaseous Microemboli Detected by Transcranial Doppler Ultrasound Stroke, December 1, 1997; 28(12): 2453 - 2456. [Abstract] [Full Text]
|
|
|
|
|
|
D. Georgiadis, A. Lindner, M. Manz, M. Sonntag, P. Zunker, H. R. Zerkowski, and M. Borggrefe Intracranial Microembolic Signals in 500 Patients With Potential Cardiac or Carotid Embolic Source and in Normal Controls Stroke, June 1, 1997; 28(6): 1203 - 1207. [Abstract] [Full Text]
|
|
|
|
|
|
U. Sliwka, A. Lingnau, W.-D. Stohlmann, P. Schmidt, M. Mull, R. R. Diehl, and J. Noth Prevalence and Time Course of Microembolic Signals in Patients With Acute Stroke: A Prospective Study Stroke, February 1, 1997; 28(2): 358 - 363. [Abstract] [Full Text]
|
|