Oral Anticoagulants in the Oldest Old with Recent Stroke and Atrial Fibrillation

Abstract

Objective To investigate the safety and effectiveness of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) after recent stroke in patients with atrial fibrillation (AF) aged ≥85 years. Methods Individual patient data analysis from seven prospective stroke cohorts. We compared DOAC versus VKA treatment among patients with AF and recent stroke (<3 months) aged ≥85 versus <85 years. Primary outcome was the composite of recurrent stroke, intracranial hemorrhage (ICH) and all‐cause death. We used simple, adjusted, and weighted Cox regression to account for confounders. We calculated the net benefit of DOAC versus VKA by balancing stroke reduction against the weighted ICH risk. Results In total, 5,984 of 6,267 (95.5%) patients were eligible for analysis. Of those, 1,380 (23%) were aged ≥85 years and 3,688 (62%) received a DOAC. During 6,874 patient‐years follow‐up, the impact of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome did not differ between patients aged ≥85 (HR≥85y = 0.65, 95%‐CI [0.52, 0.81]) and < 85 years (HR<85y = 0.79, 95%‐CI [0.66, 0.95]) in simple (pinteraction = 0.129), adjusted (pinteraction = 0.094) or weighted (pinteraction = 0.512) models. Analyses on recurrent stroke, ICH and death separately were consistent with the primary analysis, as were sensitivity analyses using age dichotomized at 90 years and as a continuous variable. DOAC had a similar net clinical benefit in patients aged ≥85 (+1.73 to +2.66) and < 85 years (+1.90 to +3.36 events/100 patient‐years for ICH‐weights 1.5 to 3.1). Interpretation The favorable profile of DOAC over VKA in patients with AF and recent stroke was maintained in the oldest old. ANN NEUROL 2022;91:78–88

Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation

“…Of note, in our study the lower hazard for the composite outcome with both DOAC regimens as opposed to VKA seemed to be mainly driven by death, consistent with prior observational studies comparing DOAC versus VKA in AF patients with recent stroke. 6,7,28 More importantly and as a novelty, our study showed that the performance of QD versus BID DOAC with regards to the composite outcome did not differ upon direct comparison among AF patients with a recent stroke. While a number of observational studies previously compared DOAC directly to one another yielding somewhat inconsistent results, [32][33][34][35][36][37] none focused on patients with recent stroke nor conducted comparisons of the QD versus BID DOAC regimen.…”

“…The primary outcome was the time to occurrence of the composite of recurrent ischemic stroke, major bleeding, and all-cause death, in accordance with prior research. [5][6][7] Secondary outcomes were the time to occurrence of each of these outcomes separately.…”

“…Of note, in our study the lower hazard for the composite outcome with both DOAC regimens as opposed to VKA seemed to be mainly driven by death, consistent with prior observational studies comparing DOAC versus VKA in AF patients with recent stroke. 6,7,28…”

“…Follow-up data were collected up to August 2021 at 3, 6, 12, and 24 months after the index event via telephone call, out-patient visit and/or from general practitioners’ and hospital records by trained study personnel using standardized electronic collection forms with predefined variables. 5–7,19–21…”

Switching from warfarin to direct-acting oral anticoagulants: it is time to move forward!

“…[ 92 ] Polymeris et al, in a multi-centre prospective cohort study, investigated the safety and efficacy of DOACs in comparison to warfarin in AF patients aged ≥ 85 years after a recent stroke (< 3 months). The study concluded that DOACs were associated with a lower risk of the composite outcome of recurrent ischemic stroke, intracranial haemorrhage, and all-cause mortality in patients with AF and recent ischemic stroke, independent of age [ 93 ].…”