Recurrent stroke in patients with history of stroke/transient ischemic attack and device-detected atrial fibrillation: A systematic review and meta-analysis

Introduction: Prolonged cardiac monitoring after stroke increases the detection of device-detected atrial fibrillation (DDAF), leading to a clinical dilemma regarding anticoagulation for secondary stroke prevention. While anticoagulation reduces thromboembolic risk in clinical AF, its benefit-risk profile in DDAF remains uncertain. Methods: In this systematic review and meta-analysis, randomized-controlled clinical trials (RCTs) evaluating anticoagulation among patients with DDAF post stroke or transient ischemic attack (TIA) were pooled. The primary efficacy outcome was any stroke recurrence, while stroke or systemic embolism, ischemic stroke recurrence, myocardial infarction, and cardiovascular mortality were assessed as secondary efficacy outcomes. The primary safety outcome was major bleeding, while hemorrhagic stroke and all-cause mortality were assessed as secondary safety outcomes. Results: Two RCTs with 599 patients (294 anticoagulation, 305 no-anticoagulation) were included. Anticoagulation significantly reduced any stroke recurrence (RR: 0.47; 95% CI: 0.23–0.94; p = 0.034; number-needed-to-treat = 34). Anticoagulation lowered the risk of the composite outcome of stroke recurrence and systemic embolism (RR: 0.45; 95% CI: 0.22–0.90; p = 0.023). However, anticoagulation was associated with an increased risk of major bleeding (RR: 2.30; 95% CI: 1.06–4.98; p = 0.035; number-needed-to-harm = 37). There were no differences in ischemic stroke recurrence (RR: 0.53; 95% CI: 0.26–1.09; p = 0.084), myocardial infarction (RR: 0.58; 95% CI: 0.17–1.96; p = 0.379), cardiovascular mortality (RR: 0.68; 95% CI: 0.35–1.34; p = 0.265), hemorrhagic stroke (RR: 0.25; 95% CI: 0.03–2.24; p = 0.217) or all-cause mortality (RR: 0.97; 95% CI: 0.66–1.41; p = 0.857). Discussion: Anticoagulation in DDAF patients with prior stroke/TIA reduces any stroke recurrence but increases major bleeding risk without raising hemorrhagic stroke incidence. This trade-off underscores the need for individualized risk stratification. Conclusions: Anticoagulation lowers any stroke recurrence in DDAF patients post-stroke/TIA but raises major bleeding risk.