Management Strategies for Patients With Atrial Fibrillation-Related Ischemic Stroke Despite Oral Anticoagulation.

BACKGROUND

In patients with atrial fibrillation-related ischemic stroke despite oral anticoagulation (AFIDA), left atrial appendage closure (LAAC) may be an additional strategy to prevent further stroke events.

METHODS AND

RESULTS

AFIDA was defined as ischemic stroke occurring despite ≥3 weeks of oral anticoagulation (OAC). We evaluated patients with AFIDA treated either with OAC alone (n=141; further divided into aggressive OAC [n=73] and conventional OAC [n=68] subgroups) or with additional LAAC (+LAAC; n=95; further divided into continued OAC [n=44] and discontinued OAC within 1 year after LAAC [n=51] subgroups). Patients in the +LAAC group were younger, had higher HAS-BLED scores, and lower HELT-E2S2scores. Three-year cumulative incidence rates of ischemic stroke and major bleeding were comparable between the OAC alone and +LAAC groups (15.2% vs. 14.5% [log-rank P=0.75] and 23.4% vs. 5.3% [log-rank P=0.38], respectively), whereas those of fatal or disabling stroke and fatal bleeding were lower in the +LAAC than OAC alone group (3.4% vs. 14.7% [log-rank P=0.06] and 0% vs. 6.0% [log-rank P=0.03], respectively). Results of propensity score-matched and subgroup analyses were largely consistent with those of the main analysis. Notably, fatal bleeding occurred only in patients switched to aggressive OAC.

CONCLUSIONS

LAAC may potentially prevent fatal or disabling stroke and fatal bleeding in patients with AFIDA. These hypothesis-generating findings support the need for randomized controlled trials.