Key result
DOACs after recent cerebral ischemia in atrial fibrillation were associated with a reduced risk of recurrent ischemic stroke, ICH, or mortality compared to VKAs (HR 0.82; 95% CI 0.67-1.00; p=0.05).
Why the study?
Outcomes after treatment with direct oral anticoagulants compared to vitamin K antagonists had not been fully compared in patients with AF and recent cerebral ischemia.
Do direct oral anticoagulants reduce the composite of recurrent ischemic stroke, intracerebral hemorrhage, or mortality compared to vitamin K antagonists in patients with atrial fibrillation and recent cerebral ischemia?
Meta-Analysis (n=4,912)
Yes
Do direct oral anticoagulants reduce the composite of recurrent ischemic stroke, intracerebral hemorrhage, or mortality compared to vitamin K antagonists in patients with atrial fibrillation and recent cerebral ischemia?
Hazard Ratio: 0.82 (95% CI 0.67–1)
p-value: p=0.05
In patients with atrial fibrillation and recent cerebral ischemia, early DOAC treatment is associated with a reduced risk of the composite of recurrent stroke, ICH, or mortality compared to VKAs, largely driven by fewer ICH events.
May favor early DOACs over VKAs after recent cerebral ischemia in AF; extends meta-analytic evidence to this high-risk group.
OBJECTIVE: We compared outcomes after treatment with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and a recent cerebral ischemia. METHODS: We conducted an individual patient data analysis of seven prospective cohort studies. We included patients with AF and a recent cerebral ischemia (<3 months before starting oral anticoagulation) and a minimum follow-up of 3 months. We analyzed the association between type of anticoagulation (DOAC versus VKA) with the composite primary endpoint (recurrent ischemic stroke [AIS], intracerebral hemorrhage [ICH], or mortality) using mixed-effects Cox proportional hazards regression models; we calculated adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS: We included 4,912 patients (median age, 78 years [interquartile range {IQR}, 71-84]; 2,331 [47.5%] women; median National Institute of Health Stroke Severity Scale at onset, 5 [IQR, 2-12]); 2,256 (45.9%) patients received VKAs and 2,656 (54.1%) DOACs. Median time from index event to starting oral anticoagulation was 5 days (IQR, 2-14) for VKAs and 5 days (IQR, 2-11) for DOACs (p = 0.53). There were 262 acute ischemic strokes (AISs; 4.4%/year), 71 intracranial hemorrrhages (ICHs; 1.2%/year), and 439 deaths (7.4%/year) during the total follow-up of 5,970 patient-years. Compared to VKAs, DOAC treatment was associated with reduced risks of the composite endpoint (HR, 0.82; 95% CI, 0.67-1.00; p = 0.05) and ICH (HR, 0.42; 95% CI, 0.24-0.71; p < 0.01); we found no differences for the risk of recurrent AIS (HR, 0.91; 95% CI, 0.70-1.19; p = 0.5) and mortality (HR, 0.83; 95% CI, 0.68-1.03; p = 0.09). INTERPRETATION: DOAC treatment commenced early after recent cerebral ischemia related to AF was associated with reduced risk of poor clinical outcomes compared to VKA, mainly attributed to lower risks of ICH. ANN NEUROL 2019;85:823-834.
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Seiffge et al. (2019) conducted a meta-analysis in Atrial fibrillation and recent cerebral ischemia (n=4,912). Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs) was evaluated on Composite of recurrent ischemic stroke (AIS), intracerebral hemorrhage (ICH), or mortality (HR 0.82, 95% CI 0.67-1.00, p=0.05). DOACs after recent cerebral ischemia in atrial fibrillation were associated with a reduced risk of recurrent ischemic stroke, ICH, or mortality compared to VKAs (HR 0.82; 95% CI 0.67-1.00; p=0.05).
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