Ischemic stroke in patients with atrial fibrillation on oral anticoagulants: characteristics and long-term outcomes

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OBJECTIVE: Patients with atrial fibrillation (AF) may experience an ischemic stroke (IS) despite oral anticoagulation (OAC). The aim of this study was to estimate the long-term risks for patients suffering an IS while taking OAC. METHODS: The study population consisted of first-ever acute IS patients prospectively collected. AF patients with IS while on OAC ("OAC-prior") were compared with OAC-naïve patients. Rates of recurrent stroke, cardiovascular events, and death were determined at 3 months and 5 years after the index stroke. RESULTS: From a cohort of 3304 consecutive patients, 653 had AF and were eligible for this analysis: 128 were OAC-prior and 525 were OAC-naïve. All patients in the OAC-prior group received vitamin K antagonists (VKA). The mean duration of follow-up was 23.8 ± 23.6 months. OAC-prior patients had more cardiovascular risk factors and a higher HASBLED score compared to OAC-naïve patients. The CHA2DS2VASC score was comparable between the two groups. Rates of stroke recurrence, cardiovascular events, and survival at 3 months (7.8% vs. 7.5%; 12.2% vs. 11.0%; 80.4% vs. 74.7%, respectively) and at 5 years (36.5% vs. 30.1%; 42.1% vs. 41.0%; 41.9% vs. 36.0%, respectively) did not differ significantly between the OAC-prior and the OAC-naïve patients. Risk of stroke recurrence was associated with the type of AF, HASBLED score, prior use of beta-blockers, and anticoagulation at discharge. CONCLUSION: The long-term risks of stroke recurrence, cardiovascular events, and all-cause mortality in AF patients experiencing IS despite receiving OAC with VKA are high. Optimal secondary prevention for AF patients who experience IS despite OAC remains to be established.

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