Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation.

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; ... (2020). Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation. (In Press). Annals of neurology Wiley-Blackwell 10.1002/ana.25700

[img]
Preview
Text
Seiffge, 2020, Ischemic stroke despite oral anticoagulant therapy.pdf - Published Version
Available under License Creative Commons: Attribution (CC-BY).

Download (530kB) | Preview

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 (OACprior ) with those without prior oral anticoagulation (OACnaive ). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OACchanged ) with those who continued the same anticoagulation as secondary prevention (OACunchanged ). 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 CHA2 DS2 -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 OACprior (n = 1,195) and OACnaive (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%). OACprior was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2-2.3, p = 0.005). OACchanged (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7-2.1, p = 0.415) compared with OACunchanged (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 CHA2 DS2 -Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high-risk patient group. ANN NEUROL 2020.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology

UniBE Contributor:

Seiffge, David Julian and De Marchis, Gian Marco

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1531-8249

Publisher:

Wiley-Blackwell

Language:

English

Submitter:

Chantal Kottler

Date Deposited:

07 Jul 2020 16:13

Last Modified:

24 Feb 2021 07:19

Publisher DOI:

10.1002/ana.25700

PubMed ID:

32052481

BORIS DOI:

10.7892/boris.145021

URI:

https://boris.unibe.ch/id/eprint/145021

Actions (login required)

Edit item Edit item
Provide Feedback