The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery...

Area of Science:

• Cardiology
• Neurology
• Pharmacology

Background:

• Atrial fibrillation (AF) patients post-stroke with concurrent indications for anticoagulation and antiplatelet therapy face complex treatment decisions.
• Optimal antithrombotic strategies for these patients, particularly those with extracranial artery stenosis (ECAS), remain debated.

Purpose of the Study:

• To compare the risks of ischemic stroke, major bleeding, and intracranial hemorrhage (ICH) among different antithrombotic strategies in post-stroke AF patients with ECAS.
• To evaluate the net clinical benefit (NCB) of various antithrombotic regimens in this high-risk population.

Main Methods:

• Retrospective cohort study using the Taiwan National Health Insurance Research Database.
• Included 6,390 post-stroke AF patients with ECAS and 28,093 without.
• Compared risks of clinical outcomes and NCB for antiplatelet (AP) monotherapy, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy, warfarin monotherapy, and combination therapies (AP + OAC).

Main Results:

• Patients with ECAS had a higher risk of recurrent ischemic stroke compared to those without (12.72%/yr vs. 10.60%/yr).
• For ECAS patients, NOAC monotherapy significantly reduced ischemic stroke, composite stroke/major bleeding, and composite stroke/ICH risks versus AP alone.
• Warfarin monotherapy and AP-OAC combinations increased major bleeding and ICH risks; NOAC monotherapy was the only strategy with a positive NCB.

Conclusions:

• NOAC monotherapy is associated with reduced adverse outcomes and a positive net clinical benefit in post-stroke AF patients with ECAS.
• Combination therapy with AP and OAC (NOAC or warfarin) offers no additional benefit and increases bleeding risk, particularly with AP-warfarin.