Anticoagulant therapy in patients with cardioembolic subtype of ischemic stroke and atrial fibrillation

Aim. To evaluate the characteristics of anticoagulant therapy (ACT) use in patients with cardioembolic (CE) subtype ischemic stroke (IS) and atrial fibrillation (AF) hospitalized in a specialized vascular center.

Material and methods. A cross-sectional study was conducted at the Vascular Center of Botkin City Clinical Hospital from April 2022 to April 2023. Adults (≥18 years) with confirmed CE-subtype IS and documented AF, presenting within 12 hours of symptom onset and receiving anticoagulants for over one month prior to admission, were eligible. Patients with hemorrhagic stroke or non-CE IS subtypes, those lacking data on anticoagulant use, or those who declined to participate were excluded.

Results. Among 1.038 patients with IS, 215 (20.7%) were diagnosed with the CE subtype in the setting of AF. More than half (n=109) were not receiving ACT at the time of stroke onset. A total of 106 patients who had been on outpatient ACT were included; rivaroxaban (n=56), apixaban (n=30), dabigatran etexilate (n=11), and warfarin (n=9). The mean patient age was 77.8 years, with an average CHA₂DS₂-VASc score of 6. In 33.9% of patients, the prescribed doses of direct oral anticoagulant (DOAC) did not correspond to clinical guidelines (e.g., unjustified dose reductions of rivaroxaban and apixaban were identified). The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 7, and in-hospital mortality reached 30.2%. Elevated mortality was associated with severe stroke presentation (NIHSS score > 8 in half of the patients) and a high burden of comorbidities: hypertension in 95.2%, chronic heart failure in 60.4%, type 2 diabetes mellitus in 30.1%, and prior myocardial infarction in 37.7% of patients.

Conclusion. The high incidence of IS despite ongoing anticoagulation highlights the need for routine monitoring of DOAC plasma levels, regular assessment of treatment adherence, and systematic education of patients and their families regarding the importance of strict adherence to prescribed anticoagulant regimens.

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