Choice of Oral Anticoagulant: Outcomes in Atrial Fibrillation Patients Post-Stroke Despite Direct Oral Anticoagulant Use

For patients with atrial fibrillation who have an ischemic stroke or transient ischemic attack (TIA) despite taking direct oral anticoagulants (DOACs), the optimal strategy for ongoing anticoagulation is unknown. Using provincial administrative databases in Alberta, Canada, we compared anticoagulant use before/after the breakthrough stroke/TIA and assessed recurrence of stroke/TIA or bleeding, with consideration of medication adherence. Adherence was defined as the proportion of days covered (PDC) being ≥ 80%. Among 985 patients, the median age was 80 years (interquartile range 13), with a mean CHADS2 score of 1.7± 1 prior to the index event. Patients were followed for a median of 643 days (interquartile range 836). Following the index stroke/TIA event, 623 patients (63%) filled a prescription for the same DOAC regimen, 83 (8%) filled a prescription for a different dose, 155 (16%) switched DOAC agents, 51 (5%) switched to warfarin, and 73 (7%) filled no oral anticoagulant prescription. Patients who kept the same regimen more commonly had TIA index events (59%); patients who changed dose or drug more often had stroke index events (55%-78%). During follow-up, 135 (14%) had stroke/TIA recurrence, and 46 (5%) had bleeding; rates of each did not differ between prescribing patterns. Post-index event, the proportion of patients with a proportion of days covered ≥ 80% improved from 55% to 80%. Although most maintained the same DOAC regimen after stroke/TIA, rates of recurrent stroke/TIA and bleeding were similar across prescribing patterns. Stroke/TIA severity may have influenced prescribing practices. DOAC prescription adherence improved poststroke/TIA and signals an opportunity for optimization in patients with atrial fibrillation. Chez les patients atteints de fibrillation auriculaire qui subissent un accident vasculaire cérébral (AVC) ischémique ou un accident ischémique transitoire (AIT) malgré la prise d’anticoagulants oraux directe (AOD), la stratégie optimale pour la poursuite de l’anticoagulation est inconnue. À partir des bases de données administratives provinciales en Alberta, au Canada, nous avons comparé l’utilisation d’anticoagulants avant/après l’AVC/AIT survenu pendant l’anticoagulothérapie et avons évalué la récurrence d’un AVC/AIT ou d’un saignement, en tenant compte de l’adhésion au traitement médicamenteux. L’adhésion a été définie comme une proportion de jours couverts (PJC) de 80 % ou plus. Chez 985 patients, l’âge médian était de 80 ans (éc