Abstract WP316: The Risk of Recurrent Ischemic Stroke in patients on DOAC: A Retrospective analysis

The increased use of direct oral anticoagulants (DOACs) is associated with a reduction in acute ischemic stroke (AIS) rates. However, the incidence of recurrent stroke while on DOAC can reach almost 5%. Currently, there is no consensus on the optimal management approach. The purpose of this study is to assess the risk of recurrent stroke in patients receiving DOACs - prevalence, risk of recurrence, and preventive strategies. METHODS: This is a single-center retrospective analysis from January 2020 to August 2024. Inclusion criteria were age>18, documented recurrent ischemic stroke while on DOAC therapy, documented compliance with DOAC regimen, stroke etiology concerning cardioembolic or embolic source of other determined etiology. Strokes due to LAA, ESUS, and SVD were excluded from the study. RESULTS: The study included 347 patients, of whom nearly 75% (258) had AIS of cardioembolic or stroke of other determined etiology. Of those, 43.5% were female, 78.1% were white, with a mean age of 69.5 years (SD 12.4). Following a first stroke, physicians’ preference resulted in 126 patients being either continued on the same DOAC (n=55; 42.6%; 34.3%-51.3%) or switched to a different DOAC (n=71; 55.0%; 42.6%-63.5%), and 3 patients were taken off DOACs. The other 129 patients were either lost to follow-up, transitioned to comfort care, or deceased. After 1 year, the overall risk of a recurrent stroke was low (7.5%; 3.6%-13.7%). Patients who were continued on the same DOAC (10.2%) had 1.8 times higher risk of recurrent stroke compared to patients who were switched to another DOAC (5.6%), though this difference was not significant. The physicians' top 5 preferences after the first time stroke were to continue with Apixaban (21.7%), switch Apixaban to Rivaroxaban (19.4%), switch Rivaroxaban to Apixaban (15.5%), switch Apixaban to Warfarin (10.1%), and continue with Rivaroxaban (7.0%). A subgroup analysis showed no significant difference in the rate of recurrent stroke among these DOACs. CONCLUSION: The risk of AIS persists in patients on DOACs, even with documented compliance and appropriate dosing. However, the overall risk of recurrent AIS appears low after employing preventive strategies, such as continuing or switching DOACs. In our analysis, continuing the same DOAC was associated with a higher—but not statistically significant—risk of recurrence compared to switching. Larger, prospective studies are needed to determine whether switching DOACs offers a protective benefit.