Objective:

To evaluate the short-term outcomes of switching oral anticoagulant therapy versus continuing the same direct oral anticoagulant (DOAC) after a breakthrough ischemic stroke in patients with atrial fibrillation.

Approach:

Key Findings:

• Event rates were similar: 5% for both switching and continuing the same DOAC.
• Recurrent ischemic stroke occurred in approximately 3% of patients in both groups.
• Symptomatic intracerebral hemorrhage occurred in about 1% of patients in both groups.
• Noninferiority was not formally demonstrated for broader composite outcomes or mortality.

Interpretation:

Switching anticoagulant therapy after a breakthrough stroke does not provide a clinically meaningful short-term benefit compared to continuing the same DOAC in patients receiving appropriate treatment.

Limitations:

• Observational design limits causal inference and may include residual confounding.
• Treatment changes during follow-up were not systematically captured.
• Findings may not be generalizable due to the study's focus on high-volume tertiary stroke units.

Conclusion:

Routine switching of anticoagulant therapy in response to breakthrough ischemic stroke may not be necessary when patients are on uninterrupted treatment, though clinical decisions should consider individual patient circumstances.

Sources:

• JAMA Network Open
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