Atrial Fibrillation and Stroke: Predictors of Anticoagulation Therapy Modification
Lara Carvalho de Oliveira1, Andrew Webb1, Ana Ponciano1, Suzete Nascimento Farias da Guarda1, Pinar Yilmaz2, Aneesh Singhal1, Anand Viswanathan1, Syed Asad3
1Massachusetts General Hospital, 2Erasmus University Rotterdam, 3Hartford Hospital/University of Connecticut
Objective:
Analyze predictors of therapy modification in patients with atrial fibrillation (AF) experiencing stroke despite adequate anticoagulation (AC) for secondary stroke prevention.
Background:
The ideal strategy to treat persons with AF experiencing stroke despite adequate AC with direct-acting anticoagulants (DOACs) or vitamin K antagonists (VKAs) is not known.
Design/Methods:
Patients admitted between 2012 and 2021 at our hospital with stroke despite AC for AF were enrolled. Baseline characteristics including National Institute of Health Stroke Scale (NIHSS), AC therapy, modified Rankin Scale (mRS), occurrence of intracerebral hemorrhage (ICH) on first image, and discharge antithrombotic therapy were collected. Logistic regression analyses were performed to identify factors associated with the decision to change AC after stroke.
Results:
595 patients were included. Of these, 291 (48.9%) were on DOACs therapy and 125 (43%) had their AC modified from DOACs at discharge (16% switched to warfarin, 58.4% to no AC and 25.6% to antiplatelet agents or enoxaparin). Of the 304 patients using VKAs, 53% had their discharge antithrombotic modified, with 26% switched to DOACs. Therapy change in patients on DOACs was associated with older age (OR 1.04, 95%CI 1.01-1.06), higher admission NIHSS (OR 1.06, 95%CI 1.03-1.10), discharge mRS ≥3 (OR 3.51, 95%CI 1.98-6.49), and ICH (OR 5.67, 95%CI 2.99-11.35). For warfarin, therapy change was associated with older age (OR 1.03, 95%CI 1.01 1.06), higher NIHSS (OR 1.04, 95%CI 1.00-1.07), heart failure (OR 1.90, 95%CI 1.13-3.27) and ICH (OR 3.81, 95%CI 1.93-8.14). Patients discharged with DOACs, compared to those with warfarin, were more likely to be younger, had higher rates of cardiovascular risk factors and ICH, and lower admission NIHSS.
Conclusions:
Older age, more severe strokes, and occurrence of ICH were associated with the decision to change or stop AC. Variation in practice exists and further research is needed to assess the clinical impact of antithrombotic therapy modification in this population.