European Heart Journal

doi: 10.1093/eurheartj/ehad119pmid: 36988155

Graphical AbstractGraphical AbstractIn case of ongoing major bleeding, rapid and effective restoration of normal hemostatic functions with reversal agents on top of standard supportive measures may be required to successfully stop the bleeding. When major bleeding risk can be anticipated (e.g. due to the need for urgent invasive surgical procedures), antithrombotic drug removal and some reversal strategies may be considered before proceeding to surgery to mitigate perioperative bleeding risk. Bold text indicates reversal agents, parentheses indicate antithrombotic drugs that are reversed. Ab, antibody; DOACs, direct oral anticoagulants; VKA, vitamin K antagonists.

doi: 10.1093/eurheartj/ehad200pmid: 37038327

AimsThe prognosis of patients with atrial fibrillation (AF) and ischemic stroke while taking oral anticoagulation is poorly understood. This study aimed to characterize the outcomes of patients following a stroke event while on oral anticoagulation.Methods and resultsIndividual participant data from five pivotal randomized trials of antithrombotic therapy in AF were used to assess the outcomes of patients with a post-randomization ischemic stroke while on study medication (warfarin, standard-, or lower-dose direct oral anticoagulant regimen) during trial follow-up. The primary outcome was recurrent ischemic stroke after the first post-randomization ischemic stroke. The primary analysis included 1163 patients with a first post-randomization ischemic stroke while on study medication (median age 73 years, 39.3% female, 35.4% history of stroke before trial enrollment). During a median continued follow-up of 337 days, 74 patients had a recurrent ischemic stroke [cumulative incidence at 1 year: 7.0%, 95% confidence interval (CI) 5.2%–8.7%]. The cumulative incidence of mortality at 3 months after stroke was 12.4% (95% CI 10.5%–14.4%). Consistent results for the incidence of recurrent ischemic stroke at 1 year were obtained in an analysis accounting for the competing risk of death (6.2%, 95% CI 4.8%–7.9%) and in a landmark analysis excluding the first 2 weeks after the index stroke and only including patients without permanent study drug discontinuation since then (6.8%, 95% CI 4.6%–8.9%).ConclusionPatients with AF and ischemic stroke while on oral anticoagulation are at increased risk of recurrent ischemic stroke and death. These patients currently have an unmet medical need.