Abstract
Background and aims
Breakthrough stroke despite oral anticoagulation (OAC) for atrial fibrillation (AF) is associated with unfavorable prognosis. We assessed the long-term outcomes and treatment-related prognostic factors of patients with stroke under OAC for AF.
Methods
Prospective data from consecutive patients with anterior ischemic stroke, AF and carotid imaging from 10 stroke registries were included.
Outcomes assessed were stroke recurrence, major adverse cardiovascular events (MACE), and mortality. Multivariable Cox-regression was performed to identify independent predictors for every outcome.
Results
Among 2,551 patients, 1,725 discharged on OAC. At 5 years, 9.6% experienced a recurrence, 33.4% a MACE and 27.2% died. Patients with breakthrough stroke had higher risk of recurrence at 12 months (HR 2.14; 95%CI 1.17–3.89) and 5 years (HR 2.06; 95%CI 1.32–3.22). At 5 years, breakthrough stroke was independently associated with increased MACE risk (HR 1.37; 1.06–1.79). Compared with vitamin K antagonists, DOACs were associated with lower stroke (HR 0.57; 0.33–1.00) and MACE risk (HR 0.69; 0.50–0.95). Statins were associated with lower risk of stroke (HR 0.68; 0.46–0.99), MACE (HR 0.65; 0.52–0.81), and mortality (HR 0.52; 95%CI 0.39–0.68). Advanced age (HR 1.06/year; 1.04–1.07), diabetes (HR 1.53; 1.16–2.02), coronary artery disease (HR 1.51; 1.11–2.06), and cancer (HR 3.16; 2.12–4.71) were associated with higher mortality.
Conclusions
Patients with breakthrough stroke despite OAC treatment represent a high-risk population with significantly worse long-term outcomes. DOAC and statin therapy remain the standard of care and warrant emphasis in secondary prevention strategies.