Fibrinogen Albumin Ratio and Ischemic Stroke During Venoarterial Extracorporeal Membrane Oxygenation

Abstract

Fibrinogen is a clotting factor and a major determinant of platelet aggregation. Albumin, on the other hand, inhibits platelet function and thrombus formation. Taken together, an elevated fibrinogen albumin ratio (FAR) has been described as a marker of disease severity during prothrombotic conditions. We evaluated the association of FAR and ischemic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. A single center, retrospective study was performed including all adult patients placed on VA ECMO. FAR was calculated from fibrinogen and albumin measurements in the first 24 hours of VA-ECMO initiation. Patients were categorized into high (≥125) and low (<125) FAR groups and the risk of eventual ischemic stroke was determined. There were 201 patients who underwent VA ECMO placement and 157 had a FAR. They were 56 ± 14 years old and 66 (42%) had a high FAR. Patients with a high FAR had lower survival free from an ischemic stroke during VA ECMO (log rank p < 0.001; adjusted hazard ratio 5.51; 95% CI: 1.8–16.5). In tertile analysis, the level of FAR was associated with an incrementally higher likelihood of eventual ischemic stroke (log rank p = 0.004). Those with a high FAR had greater mean platelet volume (10.8[10.4–12] vs. 10.5[10.2–11.9]fl, p = 0.004). An elevated FAR during the first 24 hours of VA ECMO placement is associated with a greater risk of a subsequent ischemic stroke. Our findings suggest that assessment of FAR soon after VA ECMO placement may assist with early stratification of patients at risk for an ischemic stroke.

High fibrinogen‐to‐albumin ratio is associated with hemorrhagic transformation in acute ischemic stroke patients

“…In particular, interaction of ALB with FIB may dampen FIB activity and decrease the fibrin build‐up (Galanakis, 1992). Owing to such synergy, the FAR is correlated with inflammation and has been proven to be a promising predictor of disease progression and poor long‐term prognosis in patients with coronary artery disease (Çetin et al., 2019; Xiao et al., 2019), malignancies (Zhang & Xiao, 2019), and stroke (Acharya et al., 2020). Our findings suggest that calculation of FAR on admission may assist clinicians in identifying patients at elevated risk of HT.…”

“…Inflammation has been considered as an important cause of the blood–brain barrier (BBB) disruption, which may directly lead to HT (Sandoval & Witt, 2008). Fibrinogen‐to‐albumin ratio (FAR), a new inflammatory marker, has been proposed and reported currently (Acharya et al., 2020). The predictive and prognostic value of FAR has recently been proposed in a range of diseases, including cardiovascular disease (Liang et al., 2018; Xiao et al., 2019), stroke (Acharya et al., 2020), and obstructive sleep apnea (Hizli et al., 2020).…”

“…Fibrinogen‐to‐albumin ratio (FAR), a new inflammatory marker, has been proposed and reported currently (Acharya et al., 2020). The predictive and prognostic value of FAR has recently been proposed in a range of diseases, including cardiovascular disease (Liang et al., 2018; Xiao et al., 2019), stroke (Acharya et al., 2020), and obstructive sleep apnea (Hizli et al., 2020). Fibrinogen (FIB) is not only an essential component of the coagulation cascade but also an acute‐phase reactant reflecting a state of systemic inflammation (Davalos & Akassoglou, 2012; Ryu et al., 2009).…”

Anti-Factor Xa–Based Anticoagulation during Extracorporeal Membrane Oxygenation: Potential Problems and Possible Solutions

“…However, there are studies demonstrating that high fibrinogen levels (e.g., fibrinogen/albumin ratio) may result in thrombotic events in ECMO patients. 42 Additionally, studies on fibrinogen supplementation in deficient patients demonstrate that increasing the fibrinogen levels reduces the clotting times at thromboelastometry. 43 During ECMO, the heparin dose is often increased in a time-dependent fashion, 5 suggesting that high fibrinogen levels may require a larger heparin dose to maintain the ACT/APTT at the target value.…”

Fibrinogen–Albumin-Ratio is an independent predictor of thromboembolic complications in patients undergoing VA-ECMO

“…So far, data on the prognostic value of FAR for patients with VA-ECMO are scarce. A retrospective cohort study revealed that an elevated FAR within the first 24 h after initializing VA-ECMO therapy was associated with a higher risk of ischemic stroke 17 . To our best knowledge, the association between FAR and TeC in general has not been investigated yet.…”