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Off-Label NOACs vs. Antiplatelets in AF-Related Stroke with GFR < 15 mL/Min/1.73 m2: A Multicenter Outcome Study.

Jong-Hee Sohn1,2, Minwoo Lee3, Chulho Kim1,2

  • 1Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea.

Biomedicines
|December 30, 2025
PubMed
Summary

For patients with atrial fibrillation-related stroke and very low kidney function, non-vitamin K antagonist oral anticoagulants (NOACs) may reduce stroke recurrence but increase bleeding and mortality risks compared to antiplatelet therapy.

Keywords:
AF-related strokeNOACantiplateletdialysisend-stage renal diseasemajor bleedingstroke recurrenceultra-low GFR

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Area of Science:

  • Neurology
  • Nephrology
  • Pharmacology

Background:

  • Evaluating off-label non-vitamin K antagonist oral anticoagulants (NOACs) versus antiplatelet therapy (APT) for atrial fibrillation-related acute ischemic stroke (AIS) in patients with estimated glomerular filtration rate (GFR) < 15 mL/min/1.73 m².
  • Assessing efficacy and safety in a vulnerable patient population with severe renal impairment.

Purpose of the Study:

  • To compare the effectiveness and safety of NOACs versus APT in patients with AF-related AIS and ultra-low GFR.
  • To determine the impact on stroke recurrence, major bleeding, and all-cause mortality within one year.

Main Methods:

  • Utilized a multicenter prospective stroke registry to identify eligible patients.
  • Compared outcomes between patients discharged on APT alone versus low-dose NOACs alone.
  • Employed Cox proportional hazards regression to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

Main Results:

  • 176 patients received NOACs and 135 received APT.
  • NOAC use was linked to significantly lower ischemic stroke recurrence (aHR 0.54, 95% CI 0.29-0.99).
  • NOAC use was associated with higher risks of major bleeding (aHR 3.25, 95% CI 1.84-5.73) and all-cause mortality (aHR 2.65, 95% CI 1.60-4.38).

Conclusions:

  • Off-label NOAC use in AF-related stroke patients with ultra-low GFR may improve stroke prevention but carries increased bleeding and mortality risks.
  • Non-vascular events like sepsis were the primary causes of death.
  • Individualized treatment strategies and close monitoring are crucial for this high-risk group.