2026 American Academy of Neurology Abstract Website

Rami Morsi¹, Elena Badillo Goicoechea², Ahmad Chahine¹, Yee Kuang Cheng⁵, Mehdi Abbasi⁶, Adeel Zubair⁶, Adam De Havenon⁶, Ian Yahnke⁷, Bryce Casteigne⁷, Yasmin Aziz⁷, Tiffany Brown⁸, Setareh Salehi Omran⁸, Raman Singh⁹, Maryam Haq⁹, Faddi Saleh Velez⁹, Anne Coogan¹⁰, Tamer Ghanayem¹⁰, Deborah Kerrigan¹⁰, Liqi Shu¹¹, Daniel Mandel¹², Dalia Chahien¹¹, Christoph Stretz¹¹, Karen Furie¹¹, Farid Khasiyev¹³, Guillermo Linares¹³, Andrea Arevalo¹⁴, Ekaterina Bakradze¹⁴, Isobel MacKenzie¹⁵, Mohammad Khasawneh¹⁶, Fatih Koc¹⁶, Meghna Hegde¹⁷, Abid Qureshi¹⁷, Ana Herning¹⁸, Piers Klein¹⁸, Thanh Nguyen¹⁸, Muhammad Rizwan Husain¹⁹, Umer Rizwan¹⁹, Aaron Rothstein²⁰, Jens Witsch²⁰, Donna George²⁰, Issam Awad³, Sonam Thind¹, Atman Shah⁴, Sandeep Nathan⁴, Elisheva Coleman¹, James Brorson¹, James Siegler¹, Shyam Prabhakaran¹, Ali Mansour¹, Shadi Yaghi¹¹, Tareq Kass-Hout¹
¹Department of Neurology, ²Department of Public Health Sciences, ³Department of Neurological Surgery, ⁴Department of Cardiology, University of Chicago, ⁵Department of Neurology, St. Luke’s Boise Medical Center, ⁶Department of Neurology, Yale University, ⁷Department of Neurology, University of Cincinnati, ⁸Department of Neurology, University of Colorado School of Medicine, ⁹Department of Neurology, University of Oklahoma Health Sciences, ¹⁰Department of Neurology, Vanderbilt University Medical Center, ¹¹Department of Neurology, Brown University, ¹²Department of Neurology, West Virginia University, ¹³Department of Neurology, Saint Louis University, ¹⁴Department of Neurology, University of Alabama at Birmingham, ¹⁵Washington University in St. Louis, ¹⁶Department of Neurology, Washington University in St. Louis, ¹⁷Department of Neurology, University of Kansas Medical Center, ¹⁸Department of Neurology, Boston Medical Center, ¹⁹Department of Neurology, West Virginia University Health Sciences, ²⁰Department of Neurology, University of Pennsylvania Perelman School of Medicine

Objective:

To compare the effectiveness and safety of direct oral anticoagulants (DOACs) versus warfarin for secondary stroke prevention in patients with LVEF ≤30%.

Background:

The optimal anticoagulant for secondary stroke prevention in patients with reduced left ventricular ejection fraction (LVEF ≤30%) remains uncertain. This study aimed to compare the effectiveness and safety of direct oral anticoagulants (DOACs) versus warfarin for secondary stroke prevention in patients with LVEF ≤30%.

Design/Methods:

We conducted a multicenter retrospective cohort study across 15 U.S. sites from 2016 to 2022. Patients with LVEF ≤30% following ischemic stroke (IS) who received either DOACs or warfarin were included; those on any antiplatelet regimen prior to any outcome event were excluded. The primary outcome was a composite of recurrent IS and all-cause mortality. The secondary outcome was a composite of intracranial hemorrhage and major extracranial bleeding. Inverse propensity-score weighted Cox proportional hazards models adjusted for demographics, comorbidities, and treatment imbalances. Pooled models with interaction terms assessed modification of treatment effects by left ventricular thrombus (LVT) status.

Results:

Of 771 screened patients, 370 met inclusion criteria (264 [71.4%] DOACs; 106 [28.6%] warfarin). The annualized incidence of recurrent stroke was 5.94 per 100 patient-years for DOACs and 2.93 for warfarin. Mortality rates were similar (11.53 vs 11.56 per 100 patient-years). Adjusted analyses showed no significant difference in the primary composite outcome for DOACs versus warfarin (HR 1.09, 95% CI 0.62-1.93, p=0.75), nor in bleeding or intracranial hemorrhage. Bootstrap analyses confirmed the stability of these findings.

Conclusions:

DOACs demonstrated comparable effectiveness and safety to warfarin for secondary stroke prevention in patients with LVEF ≤30%, supporting their use as a reasonable alternative in this population.