Recurrent stroke despite correct anticoagulation therapy with DOACs: Analysis of the real-life therapeutic approach

Abstract

Introduction and objectives

Recurrent strokes persist despite the use of guideline-recommended direct oral anticoagulants (DOACs). There is a scarcity of data concerning the current and optimal practices following a recurrent stroke while on DOACs. Consequently, our aim was to identify factors associated with this residual risk and to discern the current practice patterns among cardiologists and neurologists.

Methods

All consecutive patients with an acute cerebrovascular accident of any type and a diagnosis of atrial fibrillation (AF) were retrospectively screened at our stroke center. We gathered demographic information, clinical risk scores (CHA₂DS₂-VASc and HAS-BLED), echocardiographic and laboratory findings, risk factors, the modified Rankin score, and information about the treatment modality. DOAC usage was classified as either inappropriate (due to self-reported non-adherence and/or incorrect DOAC dosage) or appropriate.

Results

A total of 77 patients with stroke despite treatment with DOACs were included in the analysis. Of these, 28 (36%) had received inappropriate treatment (20 of them due to inadequate dosing). These patients tended to be older (P = .06) and had lower creatinine levels than the group receiving appropriate DOACs (0.9 vs 1; P = .01). At hospital discharge following the index stroke, various anticoagulants were administered to 75 patients (enoxaparin, n = 5; warfarin, n = 10; DOAC, n = 60). Two patients died and 20 patients were given antiplatelet therapy in addition to anticoagulants. The preferred DOACs after stroke were apixaban (n = 27), followed by rivaroxaban (n = 16), dabigatran (n = 14) and edoxaban (n = 3).

Conclusions

There is no standardized model or consensus among physicians regarding anticoagulant management. Despite the intended use of the drugs, strokes continue to occur in some patients. The 25% of strokes are related to inadequate dosage.