Inadequate Anticoagulation for Stroke Prevention in Patients with Atrial Fibrillation

We sought to determine prevalence of and associated ischemic stroke risk of non-adherence with or planned interruption of anticoagulation. Retrospective case series of acute ischemic stroke with large vessel occlusion who underwent endovascular therapy between January 2015 and January 2020 at one academic center in the United States. 102 patients with known atrial fibrillation underwent endovascular therapy for large vessel occlusion. No medication was prescribed for forty-five patients (44%), of which forty had a CHA 2 DS 2 -VASc of 2 and above. Four (4%) had warfarin held for elective surgery (between 4-11 days) and four (4%) noted poor compliance with warfarin. Among patients on direct oral anticoagulants, ten (10%) had medication held for elective surgery or hospitalization (between 2- 23 days), fourteen (14%) noted poor compliance, and four (4%) had inappropriate dosing or indication. This represents 81 patients (79%) in which hospitalization, disability, or death may have been preventable. No differences in baseline characteristics or outcome was seen between patients with anticoagulation prescription and patients without prescription on admission. Our patient cohort support the need to minimize time off anticoagulation in anticipation for elective surgical procedures to 24-48 hours for DOACs and < 5 days for VKA. A multidisciplinary approach with clear patient instructions, and risk / benefit discussions are crucial to avoid these negative consequences and obtain maximal benefit from anticoagulation.