Clinical Outcomes of Switching vs. Continuing Direct Oral Anticoagulants (DOACs) After Ischemic Stroke in Patients with Atrial Fibrillation in the US
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Background
Clinical outcomes of switching versus continuing direct oral anticoagulant (DOAC) among atrial fibrillation (AF) patients who experienced an ischemic stroke despite receiving DOAC therapy are uncertain.
Methods
We included patients with AF who were hospitalized for ischemic stroke (index stroke) between January 1, 2016, and June 30, 2022, while receiving DOAC therapy and who resumed DOAC within 90 days after discharge in the Merative MarketScan Commercial and Medicare databases. Patients were classified as DOAC-switched or DOAC-continued according to whether the DOAC agent changed or remained the same after the index stroke; secondary analyses considered individual DOACs. The primary outcome was recurrent ischemic stroke; secondary outcomes included major bleeding and a composite outcome (bleeding or ischemic stroke). Propensity score–based overlap weighting and weighted Cox models were used to estimate adjusted hazard ratios (aHRs).
Results
A total of 1175 patients were eligible for the study, of whom 970 (82.6%) continued and 205 (17.4%) switched DOAC therapy. Comparing DOAC-switched to DOAC-continued was not significantly associated with recurrent ischemic stroke (aHR, 1.20; 95% CI, 0.63-2.30), major bleeding (aHR, 0.60; 95% CI, 0.21-1.72), or the composite outcome (aHR, 0.98; 95% CI, 0.56-1.70). However, among patients who received apixaban before stroke, switching to rivaroxaban was associated with a higher risk of recurrent ischemic stroke (aHR, 2.70; 95% CI, 1.05–6.95).
Conclusions
Overall, switching DOAC therapy after ischemic stroke was not associated with improved clinical outcomes. Switching from apixaban to rivaroxaban, however, could increase risk of recurrent ischemic stroke.
Clinical Perspective
What Is New?
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Among patients with atrial fibrillation who experienced ischemic stroke while receiving DOAC therapy, switching to another DOAC was not associated with lower risks of recurrent ischemic stroke or major bleeding compared with continuing the same DOAC.
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Switching to a DOAC with a different mechanism of action or adding antiplatelet therapy was not associated with improved outcomes, whereas switching from apixaban to rivaroxaban was associated with a higher risk of recurrent ischemic stroke.
What Are the Clinical Implications?
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These findings support current guideline recommendations against anticoagulant switching or antiplatelet addition after ischemic stroke during DOAC therapy, although individual DOAC selection may still influence recurrent stroke risk.
