Premium
Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation
Author(s) -
Seiffge David J.,
De Marchis Gian Marco,
Koga Masatoshi,
Paciaroni Maurizio,
Wilson Duncan,
Cappellari Manuel,
Macha, MD Kosmas,
Tsivgoulis Georgios,
Ambler Gareth,
Arihiro Shoji,
Bonati Leo H.,
Bonetti Bruno,
Kallmünzer Bernd,
Muir Keith W.,
Bovi Paolo,
Gensicke Henrik,
Inoue Manabu,
Schwab Stefan,
Yaghi Shadi,
Brown Martin M.,
Lyrer Philippe,
Takagi Masahito,
Acciarrese Monica,
Jager Hans Rolf,
Polymeris Alexandros A.,
Toyoda Kazunori,
Venti Michele,
Traenka Christopher,
Yamagami Hiroshi,
Alberti Andrea,
Yoshimura Sohei,
Caso Valeria,
Engelter Stefan T.,
Werring David J.
Publication year - 2020
Publication title -
annals of neurology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 4.764
H-Index - 296
eISSN - 1531-8249
pISSN - 0364-5134
DOI - 10.1002/ana.25700
Subject(s) - medicine , atrial fibrillation , interquartile range , stroke (engine) , hazard ratio , vitamin k antagonist , diabetes mellitus , cardiology , cohort , prospective cohort study , rivaroxaban , warfarin , confidence interval , mechanical engineering , engineering , endocrinology
Objective It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. Methods We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OAC prior ) with those without prior oral anticoagulation (OAC naive ). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OAC changed ) with those who continued the same anticoagulation as secondary prevention (OAC unchanged ). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine–Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Results We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71–84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2–12]). The median CHA 2 DS 2 ‐Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65–74 years, sex category) was 5 (IQR = 4–6) and was similar for OAC prior (n = 1,195) and OAC naive (n = 4,119, p = 0.103). During 6,128 patient‐years of follow‐up, 289 patients had AIS (4.7% per year, 95% CI = 4.2–5.3%). OAC prior was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2–2.3, p = 0.005). OAC changed (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7–2.1, p = 0.415) compared with OAC unchanged (n = 585). Interpretation Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA 2 DS 2 ‐Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high‐risk patient group. ANN NEUROL 2020;87:677–687