Clinical outcomes among patients with active cancer and acute ischemic stroke treated with antiplatelet versus...

Patients with acute ischemic stroke and active cancer face high risks of recurrent stroke and death. Evidence guiding antithrombotic selection remains limited.

To investigate post-acute ischemic stroke prescribing patterns of antiplatelet versus anticoagulant therapy in acute ischemic stroke patients with active cancer and their associated clinical characteristics and outcomes.

We retrospectively analyzed 2003-2024 data from the Acute Stroke Registry and Analysis of Lausanne. We included patients with active cancer discharged after index acute ischemic stroke on antiplatelet therapy (single or dual) or anticoagulation (±antiplatelet therapy). We excluded patients with no or inactive cancer, missing data on discharge antithrombotics, cancer diagnosed after hospitalization, and those who died or entered palliative care before treatment decisions. The primary outcome was a recurrent ischemic cerebrovascular event within 12 months. Secondary outcomes included 3-month ischemic cerebrovascular recurrence, modified Rankin Scale shift, and all-cause mortality. The safety outcome was symptomatic intracranial hemorrhage at 3 and 12 months. We used multivariable regression models adjusted for prognostic variables.

Among 8035 patients with acute ischemic stroke, 313 had active cancer and met eligibility criteria. Median age was 73 years (interquartile range = 63-79), and 111 (35%) were women. At discharge, 178 (57%) received antiplatelet therapy and 135 (43%) anticoagulation. Patients previously naïve to antithrombotic therapy (n = 150) more often received antiplatelet therapy (68% vs 32%, p < 0.001). At 12 months, ischemic cerebrovascular recurrence occurred in 28/160 (18%) patients in the antiplatelet group and 33/118 (28%) in the anticoagulation group (subdistribution hazard ratio = 0.59, 95% confidence interval = 0.33-1.04). At 3 months, the antiplatelet group had lower risks of ischemic cerebrovascular recurrence (subdistribution hazard ratio = 0.45, 95% confidence interval = 0.25-0.82) and all-cause mortality (adjusted hazard ratio = 0.61, 95% confidence interval = 0.41-0.90). Mortality at 12 months (adjusted hazard ratio = 1.16, 95% confidence interval = 0.62-2.16) and modified Rankin Scale shift at 3 months (adjusted odds ratio = 0.79, 95% confidence interval = 0.49-1.26) and 12 months (adjusted odds ratio = 0.81, 95% confidence interval = 0.48-1.37) were similar between groups. No intracranial hemorrhages were recorded.

In a registry spanning two decades, most patients with active cancer were discharged on antiplatelet therapy after acute ischemic stroke. Antiplatelet and anticoagulant groups showed similar long-term risks of ischemic cerebrovascular recurrence. Antiplatelet therapy was associated with reduced medium-term ischemic cerebrovascular recurrences and mortality, although between-group clinical differences may have contributed to these findings.Data access statement:Anonymized data are available from the corresponding author upon reasonable request and subject to a signed data transfer and use agreement.