Recurrent Ischemic Stroke in Patients With Atrial Fibrillation While Receiving Oral Anticoagulants
- PMID: 38913390
- PMCID: PMC11197012
- DOI: 10.1001/jamaneurol.2024.1892
Recurrent Ischemic Stroke in Patients With Atrial Fibrillation While Receiving Oral Anticoagulants
Abstract
Importance: Patients with atrial fibrillation (AF) can have an ischemic stroke (IS) despite oral anticoagulant (OAC) treatment. Knowledge regarding the association between OAC discontinuation and the subsequent risk of recurrent IS in patients with AF is limited.
Objectives: To determine the risk of recurrent IS in patients with AF receiving OAC and to evaluate the association between OAC discontinuation and the risk of recurrent IS.
Design, setting, and participants: This is a nationwide cohort study of patients aged 50 years or older in Denmark who had AF and an IS (entry IS) and were initiating or restarting subsequent OAC treatment after being discharged between January 2014 and December 2021. Patients were followed up for recurrent IS until June 2022. Within this study cohort, a nested case-control analysis was performed in which patients with recurrent IS were matched to patients receiving OAC who had not yet experienced a stroke. Data were analyzed from May 25, 2023, to April 18, 2024.
Exposure: Use of OAC at the time of recurrent IS or the equivalent date in matched controls based on redeemed prescriptions.
Main outcomes and measures: The primary outcome was recurrent IS. Crude and adjusted cumulative incidences of recurrent IS and all-cause mortality were calculated in cohort analyses, and adjusted odds ratios (aORs) were determined for recurrent IS associated with OAC discontinuation in nested case-control analyses.
Results: The study cohort included 8119 patients (4392 [54.1%] male; mean [SD] age, 78.4 [9.6] years; median (IQR) CHA2DS2-VASc score, 4.0 [3.0-5.0]). Over a mean (SD) follow-up of 2.9 (2.2) years, 663 patients had a recurrent IS, of whom 533 (80.4%) were receiving OAC at the time of their recurrent IS. The crude cumulative incidence of recurrent IS at 1 year was 4.3% (95% CI, 5.9%-7.1%), and the crude cumulative incidence of all-cause mortality was 15.4% (95% CI, 14.7%-16.2%). Adjusted analysis showed similar results. Patients who discontinued OACs had a higher risk of recurrent IS (89 cases [13.4%], 180 controls [6.8%]; aOR, 2.13; 95% CI, 1.57-2.89) compared with patients still receiving OAC.
Conclusions and relevance: The risks of recurrent IS and mortality were high in patients with AF despite secondary prevention with OAC, and OAC discontinuation doubled the risk of recurrent IS compared with patients who continued OAC. This finding highlights the importance of OAC continuation and the need for improved secondary stroke prevention in patients with AF.
Conflict of interest statement
Figures


References
-
- Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. doi: 10.1161/STR.0000000000000375 - DOI - PubMed
-
- Joglar JA, Chung MK, Armbruster AL, et al. ; Peer Review Committee Members . 2023 ACC/AHA/ACCP/HRS Guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi: 10.1161/CIR.0000000000001193 - DOI - PMC - PubMed
-
- Hankey GJ, Patel MR, Stevens SR, et al. ; ROCKET AF Steering Committee Investigators . Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF. Lancet Neurol. 2012;11(4):315-322. doi: 10.1016/S1474-4422(12)70042-X - DOI - PubMed
-
- Easton JD, Lopes RD, Bahit MC, et al. ; ARISTOTLE Committees and Investigators . Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol. 2012;11(6):503-511. doi: 10.1016/S1474-4422(12)70092-3 - DOI - PubMed
-
- Diener HC, Connolly SJ, Ezekowitz MD, et al. ; RE-LY Study Group . Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol. 2010;9(12):1157-1163. doi: 10.1016/S1474-4422(10)70274-X - DOI - PubMed
MeSH terms
Substances
LinkOut - more resources
Full Text Sources
Medical
Miscellaneous