• Shadi Yaghi, Nils Henninger, James A Giles, Christopher Leon Guerrero, Eva Mistry, Ava L Liberman, Daniyal Asad, Angela Liu, Muhammad Nagy, Ashutosh Kaushal, Idrees Azher, Mac GroryBrianBNeurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA., Hiba Fakhri, Brown EspaillatKierstenKNeurology, Vanderbilt University, Nashville, Tennessee, USA., Hemanth Pasupuleti, Heather Martin, Jose Tan, Manivannan Veerasamy, Charles Esenwa, Natalie Cheng, Khadean Moncrieffe, Iman Moeini-Naghani, Mithilesh Siddu, Erica Scher, Tushar Trivedi, Karen L Furie, Salah G Keyrouz, Amre Nouh, Adam de Havenon, Muhib Khan, Eric E Smith, and M Edip Gurol.
• Dpeartment of Neurology, Brown University, Providence, Rhode Island, USA shadiyaghi@yahoo.com.
• J. Neurol. Neurosurg. Psychiatr. 2021 Oct 1; 92 (10): 1062-1067.

Background And PurposeA subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH).MethodsWe included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve).ResultsAmong 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641).ConclusionAF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

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