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The Impact of Changing Antithrombotic Management in Patients With Atrial Fibrillation and Ischemic Cerebrovascular
Ehab Harahsheh1, Omer Elshaigi2, Nour Alhayek1
1Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
Insights
For patients with atrial fibrillation (AF) experiencing stroke or TIA despite anticoagulants (AC), changing AC or adding antiplatelet therapy (AP) did not reduce recurrent events. This study suggests current strategies may not improve outcomes in this high-risk group.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Patients with atrial fibrillation (AF) face a heightened risk of ischemic cerebrovascular events, even when on anticoagulant therapy (AC).
- Acute ischemic stroke (AIS) and transient ischemic attack (TIA) in AF patients on AC present a significant clinical challenge.
- Optimizing antithrombotic strategies is crucial for preventing recurrent events in this population.
Purpose of the Study:
- To evaluate the efficacy of changing anticoagulant (AC) therapy or adding antiplatelet (AP) therapy to existing AC in patients with AF who experience AIS or TIA.
- To compare the risk of recurrent AIS/TIA and major bleeding events (MBE) between patients whose AC regimen was changed versus those who continued their existing AC.
- To assess the outcomes of patients receiving AP + AC compared to those on AC alone.
Main Methods:
- A retrospective study included 185 patients with AF and a history of AIS or TIA despite AC treatment.
- Data collected included demographics, index event details, antithrombotic therapy before and after the event, recurrent AIS/TIA, and MBE.
- Cox proportional hazards models were employed to compare outcomes between different antithrombotic strategies.
Main Results:
- No significant difference in recurrent AIS/TIA was observed between patients who had their AC changed versus those who did not (HR 1.72, P = .27).
- Adding AP to AC (AP + AC) did not reduce the risk of recurrent AIS/TIA compared to AC alone (HR 1.02, P = .95).
- Rates of major bleeding events (MBE) were also similar between the compared groups.
Conclusions:
- In this cohort of AF patients experiencing AIS/TIA despite AC, modifying AC or adding AP agents did not demonstrate a reduction in recurrent ischemic cerebrovascular events.
- The findings suggest that current approaches to adjusting antithrombotic therapy in this specific patient group may not be effective in preventing further strokes or TIAs.
- Further research is warranted to identify optimal therapeutic strategies for AF patients with suboptimal outcomes on existing AC therapy.
Background:
Patients with atrial fibrillation (AF) are at increased risk of ischemic cerebrovascular events despite anticoagulants (AC). We aim to evaluate whether changing AC or adding antiplatelet therapy to anticoagulants (AP + AC) in patients with AF presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite AC, decreases the risk of recurrent AIS/TIA compared to patients continued on same AC regimen.
Methods:
Patients with AF on AC presenting with AIS or TIA at our center between 2011- 2021 were included. Data on Demographics, index event, antithrombotic therapy before and after index event, recurrent AIS/TIA, or major bleeding events (MBE) were extracted. Cox proportional hazards models were used to compare outcomes between AC unchange vs AC change, and AP + AC vs AC only groups.
Results:
One hundred eighty-five patients were included (mean age 78.3 years; 62% males, median follow-up 9 months (IQR 1-34)). Seventeen patients (9%) had AC change, 100 (54%) received AP + AC, 39 (21%) had recurrent AIS/TIA, and 27 (15%) had MBE following index event. No difference was observed between AC unchange vs AC change and AP + AC vs AC only groups regarding recurrent AIS/TIA (HR 1.72 [.65-4.57], P = .27 and HR 1.02 [.53- 1.98], P = .95, respectively) or MBE (HR .85 [.19-3.67], P = .83 and HR 1.49 [.67-3.33)], P = .33, respectively). Fourteen vascular neurologists treated this cohort and 9(64%) implemented AC changes.
Conclusion:
In this single center retrospective study of 185 patients with AF and AIS/TIA despite AC, changing AC or adding AP agents did not decrease the risk of ischemic cerebrovascular events.
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