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. 2020 Sep 11;9(9):2938.
doi: 10.3390/jcm9092938.

Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants

Jan C Purrucker  1 , Kyra Hölscher  1 , Jennifer Kollmer  2 , Peter A Ringleb  1
Affiliations

Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants

Jan C Purrucker et al. J Clin Med. .

Abstract

Background: Reducing the number of ischemic strokes in patients with atrial fibrillation despite oral anticoagulation remains an important, yet largely unsolved challenge. Therefore, we assessed the etiology of ischemic strokes despite anticoagulation with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs).

Methods: Patients with known atrial fibrillation (AF), treatment with VKA or NOAC, and acute ischemic stroke admitted between 2015 and 2018 (1st half) were identified from the hospital database. Brain imaging data were independently reviewed. An integrated etiologic classification according to the ASCOD system was made. Medication errors (admission INR <2.0 in the VKA- or NOAC-specific concentration <10 ng/mL) or dosage/dosing errors were also analyzed.

Results: Of 3610 patients screened, n = 341 were included (VKA, n = 127; NOAC, n = 214). An overall increasing rate of OAC-associated stroke per year was observed. In 95.3% of patients with adequate diagnostic work-up (n = 321/337), at least one additional potential, uncertain, or unlikely non-cardiac cause of stroke was identified. More patients in the VKA than in the NOAC group had a medication error (81/127, 63.8% vs. 102/205, 49.8%; p = 0.013).

Conclusions: Stroke risk factors despite atrial fibrillation were highly prevalent. Although less common with NOACs than VKAs, medication errors are still frequent.

Keywords: anticoagulant drugs; antithrombins; cerebral stroke; factor Xa inhibitors; vitamin K antagonist.

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Conflict of interest statement

J.C.P. has received consultation fees and travel expenses from Abbott, Akcea, Boehringer Ingelheim, Daiichi Sankyo and Pfizer, outside the submitted work. J.K. received the Olympia-Morata grant from the Medical Faculty of the University of Heidelberg, a research grant, personal fees, and lecture honoraria from Alnylam pharmaceuticals, and advises for Akcea Therapeutics. P.A.R. reports personal fees from Boehringer Ingelheim, Bayer, Pfizer, Daiichi Sankyo, and BMS, outside the submitted work. K.H. reports no competing interests.

Figures

Figure 1
Figure 1
Flow chart of study population. OAC, oral anticoagulation; LVAD, left ventricular assist device; BIVAD, biventricular assist device; TAH, total artificial heart.
Figure 2
Figure 2
Admission time trend of patients with acute ischemic stroke and known AF and oral anticoagulation. VKA, vitamin K antagonist; NOAC, non-VKA oral anticoagulant. For 2018, data were extrapolated from the first half of the year.
Figure 3
Figure 3
Visualization of the ASCOD categorization, including the relative fraction of patients with present ‘medication error’ with regard to each ASCOD category (inner red circle). Medication error was defined as either laboratory-based evidence of insufficient anticoagulation (here defined as INR < 2.0 in the VKA-, or drug-specific concentration < 10 ng/mL in the NOAC-group, respectively) and/or dosage or dosing errors. ASCOD, A: atherosclerosis; S: small-vessel disease; O: other causes; D: dissection. The category C (cardiac pathology) was set to 1 in all patients due to the known atrial fibrillation and, thus, is not presented. VKA, vitamin K antagonist; NOAC, non-VKA oral anticoagulant.
See this image and copyright information in PMC

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