Abstract TP057: Antithrombotic Use Patterns for Secondary Stroke Prevention in Ischemic Stroke Patients with Active Malignancy: The STOP-SPAM Study

Background/Objective: Active malignancy increases the risk of ischemic stroke through multiple mechanisms, including cancer-associated hypercoagulability which has led to debate regarding secondary stroke prevention strategies. We aimed to further understand and model antithrombotic decision making and recurrent stroke within this population. Design: Single-center, retrospective cohort study from a single tertiary academic cancer center, of patients with active malignancy and ischemic stroke from 2015-2021. Patients with primary hemorrhage, clear indication for antiplatelet or anticoagulant, carotid intervention, or death within 30 days were excluded. Regression identified independent predictors of antithrombotic selection. Results: 1909 patients were reviewed with 306 patients included who met inclusion criteria. A total of 237 patients were prescribed antiplatelet agents and 69 were prescribed anticoagulant after stroke. The anticoagulant cohort had a higher frequency of Black race (47.8% vs. 32.9%), lung cancer (37.7% vs. 21.5%), pancreatic cancer (18.8% vs. 5.1%), and metastatic disease (88.4% vs. 49.4%). Regression analysis found metastatic disease (OR 8.39, 95% CI 3.86-18.25, p<0.001) and simultaneous anterior and posterior circulation stroke (OR 5.77, 95% CI 3.23-10.31, p<0.001) independently predicted anticoagulant use. Hypertension, hyperlipidemia, and unilateral stroke independently predicted antiplatelet use. Within 180 days, recurrent ischemic stroke occurred in 17.4% on anticoagulation vs. 13.9% on antiplatelet therapy, and major hemorrhage in 13.0% vs. 5.1%, respectively. Summary: In a single center cohort of 306 patients with active malignancy and new ischemic stroke, metastatic disease and multi-territory infarction were found to be independent predictors of anticoagulant use for secondary prevention, while traditional vascular risk factors and unilateral stroke predicted antiplatelet use for secondary prevention. Recurrent stroke and major bleeding were more common with use of anticoagulation within 180 days, though patients often had more advanced disease. Future propensity score–matched analyses are planned to further compare recurrent stroke rates and adverse events between groups. These findings further highlight the need for prospective studies to guide secondary prevention in cancer-associated stroke.