Real-world use and impact of direct oral anticoagulants among atrial fibrillation patients with cardioembolic stroke

Q: What are the key findings of this study?

Prior use of direct oral anticoagulants in patients with atrial fibrillation significantly reduced initial cardioembolic stroke severity compared to non-users (mean NIHSS score 8.84 vs 11.58).

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Atrial fibrillation with cardioembolic stroke (n=2610). Intervention: Direct oral anticoagulants (DOACs) vs. No DOAC therapy. Primary outcome: Stroke severity at admission (mean NIHSS score) (p=<0.001).

Q: What does this research mean for the field?

Prior use of direct oral anticoagulants in patients with atrial fibrillation significantly reduces initial cardioembolic stroke severity compared to non-users. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate real-world direct oral anticoagulant usage patterns among patients with atrial fibrillation presenting with cardioembolic stroke and assess how prior anticoagulation influences initial stroke severity.

Vladislavs Sokalskis; Kaspars Kupics; Kristaps Jurjāns; N. Nesterovics; Ieva Ozoliņa; Guntis Karelis; Evija Miglāne; A E Andrejs Erglis

doi:10.3389/fneur.2026.1844341

June 18, 2026Frontiers in NeurologyOpen Access

Real-world use and impact of direct oral anticoagulants among atrial fibrillation patients with cardioembolic stroke

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Key result

Prior DOAC use in AF is linked to ~24% lower initial stroke severity vs non-users.

P<0.001
n=2,610

Figures

Why the study?

Does prior DOAC therapy reduce initial stroke severity in atrial fibrillation patients presenting with cardioembolic stroke?

Key Points

To evaluate real-world direct oral anticoagulant usage patterns among patients with atrial fibrillation presenting with cardioembolic stroke and assess how prior anticoagulation influences initial stroke severity.
Retrospectively analyzed data from N=2,610 cardioembolic stroke patients with atrial fibrillation admitted to two Latvian university hospitals between January 2022 and December 2024.
Conducted a propensity-matched analysis comparing 352 direct oral anticoagulant users with 352 non-users, matching for age, sex, arrival time, atrial fibrillation type, HAS-BLED, and CHA2DS2-VA scores.
Among all 2,610 enrolled cardioembolic stroke patients, 43.4% had known atrial fibrillation but were not on anticoagulation therapy prior to stroke onset.
In the propensity-matched analysis, direct oral anticoagulant users presented with significantly lower admission NIHSS scores than non-users (8.84 ± 6.76 vs. 11.58 ± 6.98, p < 0.0001) and better admission mRS scores (3.73 ± 1.20 vs. 4.20 ± 0.98, p < 0.001).
Patients who experienced strokes while receiving direct oral anticoagulants exhibited significantly higher left atrial volume indices than non-users (56.05 ± 19.31 vs. 46.94 ± 14.33 mL/m2, p < 0.001).

Study Design

Type

Observational (n=2,610)

Multicenter

Yes

Structured PICO

Does prior DOAC therapy reduce initial stroke severity in atrial fibrillation patients presenting with cardioembolic stroke?

P

Population

2,610 patients with atrial fibrillation presenting with cardioembolic stroke admitted to two Latvian university hospitals between January 2022 and December 2024.

I

Intervention

Prior direct oral anticoagulant (DOAC) therapy

C

Comparator

No prior anticoagulation therapy

O

Outcome

Initial stroke severity measured by mean admission NIHSS score

Main Result

Absolute Event Rate: 8.84% vs 11.58%

p-value: p=<0.001

Prior DOAC therapy in patients with atrial fibrillation who experience a cardioembolic stroke is associated with significantly reduced initial stroke severity compared to non-adherent patients.

Limitations

Does not represent data on the national level due to lack of data from smaller regional facilities
Retrospective observational design means not all information was obtained during hospitalization
Could not evaluate the impact of socioeconomic status on DOAC usage, arrival time, or stroke severity
No systematic follow-up conducted for excluded recurrent stroke cases

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Implication

Prior DOAC use was associated with milder cardioembolic strokes; hypothesis-generating and requires prospective confirmation before practice change.

Abstract

Background and aims Atrial fibrillation (AF) is a primary cause of cardioembolic stroke (CES). Non-adherence to direct oral anticoagulants (DOACs) remains a major health policy issue. This study aimed to investigate real-world DOAC usage among AF patients presenting with stroke and to evaluate the impact of prior DOAC therapy on stroke severity. Methods This retrospective study analyzed data on DOAC usage from CES patients with AF admitted to the two largest Latvian university hospitals between January 2022 and December 2024. We further compared patients’ characteristics receiving prior DOAC therapy and those who were not, confirming our findings by a propensity-matched analysis of both groups. Results Of the 2,610 CES patients enrolled, the largest subgroup (43.4%) consisted of individuals with known AF who were not on anticoagulation therapy before the stroke event. A propensity-matched analysis adjusted for demographics, arrival time, AF type, HAS-BLED, and CHA 2 DS 2 -VA score (352 patients per group) revealed that patients taking DOACs presented with significantly milder strokes than non-users (mean admission NIHSS score: 8.84 ± 6.76 vs. 11.58 ± 6.98, p < 0.001). Stroke patients on DOAC therapy demonstrated significantly larger left atrial volume indices (LAVI) than non-users (56.05 ± 19.31 vs. 46.94 ± 14.33, respectively; p < 0.001). Conclusion Non-adherence to DOACs is a substantial contributor to the CES burden. Prior DOAC use is associated with significantly reduced initial stroke severity. Patients with CES while on DOACs exhibited substantially larger left atria.

Discussion

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Cite This Study

Sokalskis et al. (2026) conducted an observational in Atrial fibrillation with cardioembolic stroke (n=2,610). Direct oral anticoagulants (DOACs) vs. No DOAC therapy was evaluated on Stroke severity at admission (mean NIHSS score) (p=<0.001). Prior use of direct oral anticoagulants in patients with atrial fibrillation significantly reduced initial cardioembolic stroke severity compared to non-users (mean NIHSS score 8.84 vs 11.58).

synapsesocial.com/papers/6a3c2343d15afadd906f9e65 https://doi.org/10.3389/fneur.2026.1844341

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Real-world use and impact of direct oral anticoagulants among atrial fibrillation patients with cardioembolic stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Real-world use and impact of direct oral anticoagulants among atrial fibrillation patients with cardioembolic stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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