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Observational Study
. 2024 Feb 1;26(2):euae033.
doi: 10.1093/europace/euae033.

Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study

Hyo-Jeong Ahn  1 , So-Ryoung Lee  1   2 , JungMin Choi  1 , Kyung-Yeon Lee  1 , Soonil Kwon  1 , Eue-Keun Choi  1   2 , Seil Oh  1   2 , Gregory Y H Lip  2   3   4
Affiliations
Observational Study

Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study

Hyo-Jeong Ahn et al. Europace. .

Abstract

Aims: Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS.

Methods and results: Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy.

Conclusion: Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.

Keywords: Antiplatelet; Antithrombotics; Atrial fibrillation; Ischaemic stroke; Oral anticoagulation.

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Conflict of interest statement

Conflict of interest: H.-J.A., J.M.C., K.-Y.L., S.K., S.O.: none. S.-R.L.: speaking fees from Bayer, BMS/Pfizer, Biosense Webster, Daiichi-Sankyo, Sanofi-Aventis, Daewoong Pharmaceutical Co., Samjinpharm, Seers Technology, Biotronik, Boston Scientific, and Medtronic. Consultant for Biosense Webster. No fees are received personally and no fees are related to this work. E.-K.C.: research grants or speaking fees from Abbott, Bayer, BMS/Pfizer, Biosense Webster, Chong Kun Dang, Daewoong Pharmaceutical Co., Daiichi-Sankyo, DeepQure, Dreamtech Co., Ltd., Jeil Pharmaceutical Co. Ltd, Medtronic, Samjinpharm, Seers Technology, and Skylabs. G.Y.H.L.: consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Anthos, and Daiichi-Sankyo. No fees are received personally. G.Y.H.L. is co-principal investigator of the AFFIRMO project on multimorbidity in AF, which has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement no. 899871.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Inclusion of study population. AF, atrial fibrillation; DC, direct current; IS, ischaemic stroke; MRI, magnetic resonance imaging; TIA, transient ischaemic attack.
Figure 2
Figure 2
Peri-stroke prescription pattern of antithrombotics. OAC, oral anticoagulant; APT, antiplatelet. Percentages may not total 100.0 because of rounding.
Figure 3
Figure 3
Cumulative risks of net clinical outcome in atrial fibrillation after discharge from the index stroke stratified by antithrombotics therapy at the first clinic visit. HR, hazard ratio; OAC, oral anticoagulant; APT, antiplatelet. Hazard ratios were adjusted by age, sex, hypertension, diabetes mellitus, stroke aetiology, and type of AF (paroxysmal AF vs. non-paroxysmal AF). *Bonferroni’s corrected P-values.
Figure 4
Figure 4
Cumulative risks of (A) recurrent stroke, (B) any bleeding, (C) hospitalization or emergency department visits for cardiovascular events, and (D) death in atrial fibrillation after discharge from the index stroke stratified by antithrombotics at the first clinic visit. HR, hazard ratio; OAC, oral anticoagulant; APT, antiplatelet. Hazard ratios were adjusted by age, sex, hypertension, diabetes mellitus, stroke aetiology, and type of AF (paroxysmal AF vs. non-paroxysmal AF). *Bonferroni’s corrected P-values.
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