Prior anticoagulation in patients with ischaemic stroke and atrial fibrillation.

Abstract

OBJECTIVE

To evaluate in patients with atrial fibrillation (AF) and acute ischaemic stroke the association of prior anticoagulation with vitamin-K antagonists (VKA) or direct oral anticoagulants (DOACs) with stroke severity, intravenous thrombolysis (IVT) utilization, safety of IVT, and 3-months outcomes.

METHODS

Cohort study of consecutive patients (2013-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/MT, symptomatic intracranial hemorrhage (sICH), and favorable outcome (mRS 0-2) at 3 months.

RESULTS

Of 8179 patients (mean[SD]age, 79.8[9.6] years;49%women), 1486(18%) were on VKA treatment, 1634(20%) on DOAC treatment at stroke onset, and 5059 controls. Stroke severity was lower in patients on DOACs (median NIHSS 4,[IQR2-11]) as compared to VKA (6,[2-14]) and controls (7,[3-15], P<0.001; quantile regression: β -2.1, 95%CI -2.6 - -1.7). The IVT-rate in potentially eligible patients was significantly lower in patients on VKA (156/247 (63%);aOR 0.67; 95%CI 0.50-0.90) and particularly in patients on DOACs (69/464 (15%); aOR 0.06; 95%CI 0.05-0.08) as compared to controls (1544/2504 (74%)). sICH after IVT occurred in 3.6%(2.6-4.7%) of controls, 9/195 (4.6%; 1.9-9.2%; aOR 0.93;0.46-1.90) of patients on VKA and 2/65 (3.1%; 0.4-10.8%, aOR 0.56;0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with favorable 3-month outcome (aOR 1.24,1.01-1.51).

INTERPRETATION

Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. This article is protected by copyright. All rights reserved.