Direct Oral Anticoagulants vs. Heparin for Cancer-Related Stroke: Augmented Meta-Analysis

Ischemic stroke is common among patients with systemic malignancy, associated with increased risk of neurological deterioration and mortality compared to the general population. Optimal approach to secondary stroke prevention in cancer patients is unclear. In this meta-analysis, we evaluated available data on the use of direct oral anticoagulants (DOACs) and heparin products for stroke prevention in this population.

Using the Nested Knowledge AutoLit software, we performed PubMed search in September 2023 for articles reporting the use of antithrombotics for cancer-associated stroke. We conducted systematic review and meta-analysis. We also used a novel computational augmentation method to amplify the sample size to predict the effect before and after sample size augmentation and predict the results of further trials.

Among 253 potential studies screened, 7 were eligible for inclusion. 439 patients were treated with DOACs and 3968 with heparin products. Among patients treated with heparin, intracerebral hemorrhage (8.8 % vs 1.6, p=.02), overall hemorrhagic complications (17.9% vs 3.5%, p<.001), and mortality [28.1% vs 23.5%, p<.001] were respectively significantly higher than those reported among patients who received DOAC for cancer-associated ischemic stroke. No significant difference was observed in the rates of recurrent deep venous thrombosis, clinically significant hemorrhage, and clinical outcomes between the treatment groups. Similar results were shown with augmented meta-analysis.

This meta-analysis shows DOACs may have efficacy and safety profile similar to heparin products for recurrent stroke prevention in patients with cancer. Given the small number of studies and limited data, findings should be interpreted with caution.