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Benz AP, Hohnloser SH, Eikelboom JW, Carnicelli AP, Giugliano RP, Granger CB, Harrington J, Hijazi Z, Morrow DA, Patel MR, Seiffge DJ, Shoamanesh A, Wallentin L, Yi Q, Connolly SJ. Outcomes of patients with atrial fibrillation and ischemic stroke while on oral anticoagulation. Eur Heart J 2023; 44:1807-1814. [PMID: 37038327 PMCID: PMC10411934 DOI: 10.1093/eurheartj/ehad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/08/2023] [Accepted: 03/20/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The prognosis of patients with atrial fibrillation (AF) and ischemic stroke while taking oral anticoagulation is poorly understood. This study aimed to characterize the outcomes of patients following a stroke event while on oral anticoagulation. METHODS AND RESULTS Individual participant data from five pivotal randomized trials of antithrombotic therapy in AF were used to assess the outcomes of patients with a post-randomization ischemic stroke while on study medication (warfarin, standard-, or lower-dose direct oral anticoagulant regimen) during trial follow-up. The primary outcome was recurrent ischemic stroke after the first post-randomization ischemic stroke. The primary analysis included 1163 patients with a first post-randomization ischemic stroke while on study medication (median age 73 years, 39.3% female, 35.4% history of stroke before trial enrollment). During a median continued follow-up of 337 days, 74 patients had a recurrent ischemic stroke [cumulative incidence at 1 year: 7.0%, 95% confidence interval (CI) 5.2%-8.7%]. The cumulative incidence of mortality at 3 months after stroke was 12.4% (95% CI 10.5%-14.4%). Consistent results for the incidence of recurrent ischemic stroke at 1 year were obtained in an analysis accounting for the competing risk of death (6.2%, 95% CI 4.8%-7.9%) and in a landmark analysis excluding the first 2 weeks after the index stroke and only including patients without permanent study drug discontinuation since then (6.8%, 95% CI 4.6%-8.9%). CONCLUSION Patients with AF and ischemic stroke while on oral anticoagulation are at increased risk of recurrent ischemic stroke and death. These patients currently have an unmet medical need.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Langenbeckstr. 1, Mainz 55131, Rhineland-Palatinate, Germany
| | | | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Robert P Giugliano
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | | | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David A Morrow
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
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