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Occurrence of ischemic stroke despite DOAC use in non-valvular AF patients? The importance of the dosing regimen
Session:
Posters 5 - Écran 07 - Cardiologia Clínica/Miscelânia
Speaker:
James Milner
Congress:
CPC 2018
Topic:
C. Arrhythmias and Device Therapy
Theme:
05. Atrial Fibrillation
Subtheme:
05.5 Atrial Fibrillation - Stroke Prevention
Session Type:
Posters
FP Number:
---
Authors:
James Milner; Ana Vera Marinho; Cátia Santos Ferreira; Luís Fernandes; Tatiana Gonçalves; João Sargento Freitas; Natália António; Mariano Pêgo; Luis Cunha
Abstract
<p><strong>Background: </strong>Direct Oral Anticoagulants (DOAC) are the mainstay of therapy for stroke prevention in patients with non-valvular Atrial Fibrillation (AF). Although unexpected, ischemic stroke may occur even in patients under DOAC. However, there is scarce real-world data about therapeutic adherence to these drugs, as well as the impact of the dosing regimen on clinical outcomes. We sought to evaluate a cohort of patients who have suffered an ischemic stroke despite being anticoagulated with DOAC due to non-valvular AF.</p> <p><strong>Population and methods: </strong>Single-center observational prospective study, of 70 consecutive patients admitted to the Neurology department over a period of a year, due to ischemic stroke despite being chronically anticoagulated with a DOAC for non-valvular AF. Patients were divided into two groups, one with once-daily dosing (group A, N=37) and the other with twice-daily dosing of DOAC (group B, N=33). Baseline clinical and demographic characteristics were compared between both groups, as well as therapeutic compliance (<em>Brief Medication Questionaire</em> (BMQ) and <em>Medida de Adesão aos Tratamentos</em> (MAT)) and the extent of the stroke according to the Oxfordshire Community Stroke Project classification.</p> <p><strong>Results: </strong>In this cohort, mean age was 79±7 years and 60% of the patients were female, with a mean creatinine clearance of 68±24 mL/min/1.73m<sup>2</sup> and a mean body mass index of 27±5 kg/m<sup>2</sup>, without significant differences between both groups. 62% had permanent AF and the average time since AF diagnosis was 4.9±4.5 years, with a mean CHA<sub>2</sub>DS<sub>2</sub>VASc score of 4.4±1.4 in the overall population and without significant differences between both groups. There was a higher proportion of patients with a CHA<sub>2</sub>DS<sub>2</sub>VASc≥5 in group A (62% vs 33%, p=0.016). There were no statistically significant differences in the proportion of patients under an infratherapeutic dose of DOAC between groups (24.3% in group A vs 42.4% in group B, p=0.108).. Despite a similar proportion of poor adherance to DOAC (43% in group A vs 50% in group B, p=0.599), total anterior circulation (TAC) strokes were significantly more common in patients with once-daily dosing (62% vs 30%, p=0.008). After multivariate analysis, adjusting for therapeutic dosing, CHA<sub>2</sub>DS<sub>2</sub>VASc and therapeutic compliance, once-daily dosing remained as an independent predictor of TAC strokes (OR 4.69, 95% CI 1.274-17.264, p=0.020).</p> <p><strong>Conclusions: </strong>Among AF patients who develop ischemic strokes despite DOAC therapy, a significant proportion of patients was under an infratherapeutic dose of DOAC or had a poor adherence to this treatment. Patients who are medicated with once-daily DOACs seem to have a higher risk of developing more extensive strokes, regardless of their thrombotic risk, adherence to therapy and correct dosing.</p>
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