Key result
Anticoagulant plus antiplatelet at discharge linked to an absolute ~16% lower 90-day stroke or death.
Why the study?
Optimal antithrombotic therapy for ischemic stroke due to symptomatic large-artery atherosclerosis in patients with atrial fibrillation remains uncertain.
Does the choice of antithrombotic regimen (e.g., single anticoagulant plus single antiplatelet vs single anticoagulant alone) improve ischemic and bleeding outcomes in patients with atrial fibrillation and symptomatic large-artery atherosclerosis?
Cohort (n=191)
Yes
Does the choice of antithrombotic regimen (e.g., single anticoagulant plus single antiplatelet vs single anticoagulant alone) improve ischemic and bleeding outcomes in patients with atrial fibrillation and symptomatic large-artery atherosclerosis?
Absolute Event Rate: 8% vs 24%
In high-risk patients with atrial fibrillation and symptomatic large-artery atherosclerosis, combining a single anticoagulant with a single antiplatelet is associated with lower short-term stroke/death but higher symptomatic bleeding compared to an anticoagulant alone.
Observed lower short-term stroke/death with anticoagulant plus antiplatelet; leaves open optimal regimen and duration pending prospective trials.
BACKGROUND: Optimal antithrombotic therapy for ischemic stroke due to symptomatic large-artery atherosclerosis in patients with atrial fibrillation remains uncertain. We describe real-world prescribing patterns and outcomes across antithrombotic regimens. METHODS: We retrospectively analyzed consecutive patients with atrial fibrillation and ischemic stroke related to symptomatic large-artery atherosclerosis (intracranial or extracranial or both) at 4 US comprehensive stroke centers. Patients were grouped by discharge regimen: single anticoagulant, single antiplatelet (sAP), single anticoagulant+sAP, dual antiplatelet therapy, or triple therapy (single anticoagulant+dual antiplatelet therapy). Outcomes were recurrent ischemic stroke, symptomatic hemorrhage, and death at 90 days and 1 year. RESULTS: Among 191 patients (median age 75 years [interquartile range [IQR], 68-83]; 40% women; 36% prior stroke/transient ischemic attack), single anticoagulant+sAP was the most common discharge regimen (33%), followed by single anticoagulant (25%), whereas triple therapy was uncommon (4%). More than half of patients switched regimens within 1 year, mostly as the planned duration ended (71%) or following an outcome event (12%). During follow-up (median 68 days [IQR, 28-120]), 21 patients (11%) had recurrent ischemic stroke, and 26 (14%) had symptomatic hemorrhage, over half of each within 90 days; 25% of deaths occurred within 90 days. Ninety-day stroke/death rate was 24%, with single anticoagulant versus 8% with single anticoagulant+sAP; symptomatic hemorrhage rate was 0% and 12%, respectively. At 1 year, stroke/death was 27.3% with sAP, 11.1% with single anticoagulant+sAP, 4.5% with single anticoagulant, and 0% with dual antiplatelet therapy. Symptomatic hemorrhage was similar across groups. CONCLUSIONS: In patients with atrial fibrillation and symptomatic large-artery atherosclerosis, recurrent ischemic events and mortality were common, and antithrombotic management varied substantially. The combination of single anticoagulant+sAP was associated with lower observed short-term stroke/death than single anticoagulant; however, bleeding remains a concern with prolonged therapy. Prospective studies are needed to define optimal regimen and duration for this high-risk population.
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Mohamed et al. (2026) conducted a cohort in Atrial fibrillation and ischemic stroke related to symptomatic large-artery atherosclerosis (n=191). Single anticoagulant + single antiplatelet vs. Single anticoagulant was evaluated on Recurrent ischemic stroke, symptomatic hemorrhage, and death at 90 days and 1 year. Discharge with a single anticoagulant plus a single antiplatelet was associated with a lower 90-day stroke or death rate (8%) compared to a single anticoagulant alone (24%).
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