Optimal use of antithrombotic agents in ischemic stroke with atrial fibrillation and large artery atherosclerosis

Abstract

Background: Optimal antithrombotic regimens to prevent recurrent stroke in patients with ischemic stroke due to AF and atherosclerotic large-vessel stenosis remains unknown. Aims: This study aimed to evaluate the effect of multiple antithrombotic therapies on outcomes at 1-year after ischemic stroke due to two or more causes. Methods: Based on the linked data, we identified 862 patients with ischemic stroke due to AF and large artery atherosclerosis in the relevant arteries. These patients were categorized into three groups, according to their antithrombotic therapies at discharge after ischemic stroke: those receiving 1) antiplatelet agents, 2) oral anticoagulants (OAC), and 3) antiplatelet agents plus OAC. The study outcomes were recurrent ischemic stroke, composite outcomes, including ischemic stroke, myocardial infarction, intracerebral hemorrhage and death, and major bleeding after 1 year. Inverse probability of treatment weighting (IPTW) was used to balance the three groups using propensity scores. Results: Among 862 patients (mean age: 72.6 years, men: 58.4%), 169 (19.6%) were treated with antiplatelet agents, 405 (47.0%) were treated with OAC, and 288 (33.4%) were treated with antiplatelet agents and OAC. After applying IPTW, only OAC had a significant beneficial effect on the 1-year composite outcome (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.23–0.60, P < 0.001) and death (HR: 0.35, [95% CI: 0.19–0.63], P < 0.001). Patients treated with a combination of antiplatelet agents and OAC had an increased risk of major bleeding complications (HR: 5.27, [95% CI: 1.31–21.16], P = 0.019) compared with those treated with antiplatelet agents alone. However, there was no significant difference in the risk of 1-year recurrent stroke among the three groups. Conclusion: This study demonstrated that OAC monotherapy was associated with lower risks of composite outcome and death in patients at 1-year after ischemic stroke due to AF and atherosclerotic stenosis. In addition, the combination of an antiplatelet agent and OAC had a high risk of major bleeding.

Antithrombotic agents and the effect on outcome in ischemic stroke with atrial fibrillation and large artery atherosclerosis: an observational study

“…Fearing of secondary bleeding may be an important reason of low combined APT and OAC therapy in our cohort. It was found that bleeding was higher in OAC combined with APT group than monotherapy group while in our study the bleeding events were of no difference between three treatment groups, partly owing to the small sample size of combined therapy (14).…”

“…In our study, OAC, APT and combination of OAC and APT were 80.8%, 14.3% and 4.9% respectively compared to that of 47.0%, 19.6% and 33.4% in another study (14). OAC was more while the combination treatment was less in our study.…”

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

“…The question arises about combining these therapies for ischemic stroke patients with AF and large-artery atherosclerosis. A study by Kim et al [57] in South Korea found no additional benefit and a greater risk associated with combining antithrombotic and antiplatelet therapy in such patients, indicating OAC monotherapy as an optimal antithrombotic regimen in preventing recurrent stroke in ischemic stroke due to AF and large-vessel atherosclerosis. However, the study had limitations, including the inclusion of individuals treated with VKAs, known for higher bleeding risk compared to direct oral anticoagulants.…”

Stroke subtypes and outcomes in China, common clinical conundrums in stroke management, and pediatric stroke

“…Anticoagulation is clearly superior in preventing AF-related strokes, but antiplatelet agents appear more efficacious for atherosclerotic-related strokes. One option is to give combination therapy, but as pointed out by Kim et al, 12 in this issue of IJS, there is a lack of randomized clinical trials supporting this approach. To address this question, they linked data from 52,213 IS cases obtained from the Clinical Research Center for Stroke (CRCS) registry of acute stroke and identified 862 patients with 1 acute IS (within 7 days of symptom onset), 2 history of AF, and 3 IS due to two or more potential causes (AF and large artery stenosis (LAA) > 50% in the relevant intracranial or extracranial vessels) according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification and linked outcome data.…”