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Early Recurrent Embolism Rheumatic Heart Disease

Robert G. Hart, MD
Arch Neurol. 1985;42(11):1033-1033. doi:10.1001/archneur.1985.04060100011001
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To the Editor.  —The issue of when to initiate anticoagulation following embolic stroke remains controversial. The retrospective study of Calandre et al1 contributes valuable data in this regard. However, several additional, pertinent studies have appeared since preparation of their article,2-7 prompting further questions about their data and conclusions.The authors concluded that "early recurrent embolic events are not frequent after embolic strokes secondary to RHD [rheumatic heart disease]" and, based on their 17 nonanticoagulated patients, "several patients were being treated with platelet-inhibiting drugs, which in some way could help against cerebral embolism."1 This conclusion seems premature because of the small numbers in their study, and it conflicts with several other studies (Table). The authors postulated that these studies, carried out before computed tomographic (CT) scans were performed, misdiagnosed hemorrhagic transformation with worsening as early recurrent embolism. However, this seems unlikely to entirely explain the higher rates of

REFERENCES

Calandre L, Ortega JF, Bermejo F:  Anticoagulation and hemorrhagic infarction in cerebral embolism secondary to rheumatic heart disease . Arch Neurol 1984;;41:1152-1154.
Cerebral Embolism Study Group:  Immediate anticoagulation of embolic stroke: Brain hemorrhage and management options . Stroke 1984;;15:779-789.
Cerebral Embolism Study Group:  Immediate anticoagulation of embolic stroke: A randomized trial . Stroke 1983;;14:668-676.
Lodder J, Yan der Lugt PJM:  Evaluation of the risks of immediate anticoagulant treatment in patients with embolic stroke of cardiac origin . Stroke 1983;;14:42-46.
Hart RG, Coull BM, Hart PD:  Early recurrent embolism associated with nonvalvular atrial fibrillation . Stroke 1983;;14:688-693.
Shields RW, Laureno R, Lachman T, et al:  Anticoagulant-induced brain hemorrhage in acute cerebral embolism . Stroke 1984;;15:426-437.
Drake ME, Shin C:  Conversion of ischemic to hemorrhagic infarction by anticoagulant administration: Report of two cases with evidence from serial computed tomographic brain scans . Arch Neurol 1983;;40:44-46.
Daley R, Mattingly TW, Holt CT, et al:  Systemic arterial embolism in rheumatic heart disease . Am Heart J 1954;;42:566-581.
Szekely P:  Systemic embolism and anticoagulant prophylaxis in rheumatic heart disease . Br Med J 1964;;1:1209-1211.
Darling RC, Austin WG, Linton RR:  Arterial embolism . Surg Gynecol Obstet 1967;;124:106-114.
Fleming HA, Bailey SM:  Mitral valve disease, systemic embolism, and anticoagulants . Postgrad Med J 1971;;47:599-604.
Santamaria J, Graus F, Peres J:  Cerebral embolism and anticoagulation . Neurology 1983;; 33:1104.
Furlan AJ, Cavalier SJ, Hobbs RE, et al:  Hemorrhage and anticoagulation after nonseptic embolic brain infarction . Neurology 1982;;32:280-288.
Koller RL:  Recurrent embolic cerebral infarction and anticoagulation . Neurology 1982;; 32:283-285.

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Calandre L, Ortega JF, Bermejo F:  Anticoagulation and hemorrhagic infarction in cerebral embolism secondary to rheumatic heart disease . Arch Neurol 1984;;41:1152-1154.
Cerebral Embolism Study Group:  Immediate anticoagulation of embolic stroke: Brain hemorrhage and management options . Stroke 1984;;15:779-789.
Cerebral Embolism Study Group:  Immediate anticoagulation of embolic stroke: A randomized trial . Stroke 1983;;14:668-676.
Lodder J, Yan der Lugt PJM:  Evaluation of the risks of immediate anticoagulant treatment in patients with embolic stroke of cardiac origin . Stroke 1983;;14:42-46.
Hart RG, Coull BM, Hart PD:  Early recurrent embolism associated with nonvalvular atrial fibrillation . Stroke 1983;;14:688-693.
Shields RW, Laureno R, Lachman T, et al:  Anticoagulant-induced brain hemorrhage in acute cerebral embolism . Stroke 1984;;15:426-437.
Drake ME, Shin C:  Conversion of ischemic to hemorrhagic infarction by anticoagulant administration: Report of two cases with evidence from serial computed tomographic brain scans . Arch Neurol 1983;;40:44-46.
Daley R, Mattingly TW, Holt CT, et al:  Systemic arterial embolism in rheumatic heart disease . Am Heart J 1954;;42:566-581.
Szekely P:  Systemic embolism and anticoagulant prophylaxis in rheumatic heart disease . Br Med J 1964;;1:1209-1211.
Darling RC, Austin WG, Linton RR:  Arterial embolism . Surg Gynecol Obstet 1967;;124:106-114.
Fleming HA, Bailey SM:  Mitral valve disease, systemic embolism, and anticoagulants . Postgrad Med J 1971;;47:599-604.
Santamaria J, Graus F, Peres J:  Cerebral embolism and anticoagulation . Neurology 1983;; 33:1104.
Furlan AJ, Cavalier SJ, Hobbs RE, et al:  Hemorrhage and anticoagulation after nonseptic embolic brain infarction . Neurology 1982;;32:280-288.
Koller RL:  Recurrent embolic cerebral infarction and anticoagulation . Neurology 1982;; 32:283-285.

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