Stroke occurrence while on antiplatelet therapy may predict atrial fibrillation detected after stroke

Stroke occurrence while on antiplatelet therapy, i.e., a breakthrough stroke, is often conveniently attributed to antiplatelet resistance. However, undetected paroxysmal atrial fibrillation (AF) may underlie breakthrough strokes. We hypothesized that a breakthrough stroke may be a clinical marker for patients at risk of having AF detected after stroke (AFDAS). Consecutive patients without known AF hospitalized for ischemic stroke between 2000 and 2013 were identified from nationwide claims data. The independent variable of interest was continued use of antiplatelet therapy within 30 days before stroke. The diagnosis of AF and comorbidities were ascertained using validated algorithms. Stroke severity (National Institutes of Health Stroke Scale [NIHSS]) was estimated using a validated claims-based method. Univariable and multivariable Cox regression analyses were used to determine the effect of breakthrough strokes on the occurrence of AFDAS separately in patients with mild and severe stroke (estimated NIHSS ≤10 versus >10). Among 17,076 patients (40% female, mean age 69 years), 3314 (19%) were on antiplatelet therapy before stroke. In patients with mild stroke, prior antiplatelet use was significantly associated with the occurrence of AFDAS (adjusted hazards ratio, 1.26; 95% confidence interval, 1.08–1.48). In contrast, no association existed between prior antiplatelet use and the risk of AFDAS in those with severe stroke. Patients with a breakthrough stroke of mild severity while on antiplatelet therapy carried an increased risk of AFDAS compared to those not on antiplatelet therapy. Our findings may help prioritize patients for advanced cardiac monitoring in daily practice. [Display omitted] •A breakthrough stroke is an ischemic stroke despite treatment with antiplatelets.•Early detection of atrial fibrillation (AF) is essential in stroke patients without known AF.•A breakthrough stroke of mild severity may predict AF detected after stroke.•Patients with a breakthrough stroke are recommended for cardiac monitoring.