Key result
Lower DOAC levels linked to increased LVO/MeVO risk in acute ischemic stroke or TIA.
Why the study?
Patients experiencing ischemic stroke or TIA despite DOAC treatment are poorly studied, and the underlying causes remain poorly understood.
Are low DOAC plasma levels associated with increased stroke severity and large/medium vessel occlusion in patients with acute ischemic stroke or TIA despite DOAC treatment?
Observational (n=163)
No
Are low DOAC plasma levels associated with increased stroke severity and large/medium vessel occlusion in patients with acute ischemic stroke or TIA despite DOAC treatment?
Effect estimate: OR 0.89 (95% CI 0.85-0.94)
p-value: p=<0.001
In patients experiencing ischemic stroke or TIA despite DOAC therapy, low DOAC levels (<50 ng/mL) are present in over 40% of cases and are associated with increased stroke severity and large/medium vessel occlusion.
May warrant checking DOAC levels in breakthrough strokes; challenges assumptions of therapeutic anticoagulation and leaves open causal validation.
Background: Ischemic stroke or transient ischemic attack (TIA) occurs in 1.4% of patients with atrial fibrillation (AF) per year despite treatment with direct oral anticoagulants (DOACs). This group of patients is poorly studied, and possible causes for this are not fully understood. Objectives: The aim of the study was to analyze DOAC plasma levels in patients who had ischemic stroke or TIA despite treatment with DOAC. Design: Monocentric retrospective study. Methods: We selected consecutive DOAC-treated patients with acute ischemic stroke or TIA, admitted during a 2-year period, with measurement of DOAC levels ⩽24 h after hospital admission. Patients with and without low DOAC levels (<50 ng/mL) were compared. Results: We included 163 patients with median age of 80 years, 46.6% of female sex. AF was the most frequent indication for DOAC (83.4%). Low DOAC levels were found in 42.3% of patients. Patients with low DOAC levels more frequently were being treated with an inappropriate low DOAC dose (29.4% vs 16.0%, p = 0.004), more frequently had unknown last DOAC intake or intake >48 h before admission (72.5% vs 57.5%, p = 0.004), and had higher baseline NIHSS (8 vs 4, p = 0.001). Lower DOAC levels were associated with large or medium vessel occlusion (LVO/MeVO; odds ratio per 10 ng/mL-increase = 0.89, 95% confidence interval = 0.85–0.94, p < 0.001). Cardiac pathology as the only potentially causal mechanism was more frequent in low DOAC levels patients (76.8% vs 60.6%, p = 0.029). Thirty patients (18.4%) had ⩾2 potentially causal mechanisms, 18 (11.0%) had potentially causal mechanisms other than cardiac pathology, and 5 (3.1%) had no identifiable potentially causal mechanism. Conclusion: In DOAC-treated patients with ischemic stroke or TIA, low DOAC levels were found in 2/5 of patients. Lower DOAC levels are associated with increased stroke severity and the presence of LVO/MeVO. The profile of stroke etiology in DOAC-treated patients varies between groups with and without low DOAC levels.
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Rust et al. (2026) conducted an observational in Acute ischemic stroke or TIA despite DOAC treatment (n=163). Low DOAC levels (<50 ng/mL) vs. DOAC levels ≥50 ng/mL was evaluated on Large or medium vessel occlusion (LVO/MeVO) (OR 0.89, 95% CI 0.85-0.94, p=<0.001). Lower DOAC plasma levels in patients with acute ischemic stroke or TIA were associated with large or medium vessel occlusion (OR per 10 ng/mL-increase 0.89; 95% CI 0.85-0.94; p<0.001).
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