Antithrombotic Therapy for Secondary Stroke Prevention in Patients With Symptomatic Large‐Artery Atherosclerosis and Atrial Fibrillation: A Multicenter Experience
8 affiliations
- 1Emory University Hospital
- 2Yale School of Medicine
- 3Medical University of South Carolina
- 4The University of Chicago Pritzker School of Medicine
- 5Virginia School of Medicine
- 6Mass General Hospital, Harvard Medical School
- 7Stanford School of Medicine
- 8Emory University Hospital, Emory School of Medicine
Abstract
BACKGROUND: Optimal antithrombotic therapy for ischemic stroke due to symptomatic large-artery atherosclerosis in patients with atrial fibrillation remains uncertain. We describe real-world prescribing patterns and outcomes across antithrombotic regimens. METHODS: We retrospectively analyzed consecutive patients with atrial fibrillation and ischemic stroke related to symptomatic large-artery atherosclerosis (intracranial or extracranial or both) at 4 US comprehensive stroke centers. Patients were grouped by discharge regimen: single anticoagulant, single antiplatelet (sAP), single anticoagulant+sAP, dual antiplatelet therapy, or triple therapy (single anticoagulant+dual antiplatelet therapy). Outcomes were recurrent ischemic stroke, symptomatic hemorrhage, and death at 90 days and 1 year. RESULTS: Among 191 patients (median age 75 years [interquartile range [IQR], 68-83]; 40% women; 36% prior stroke/transient ischemic attack), single anticoagulant+sAP was the most common discharge regimen (33%), followed by single anticoagulant (25%), whereas triple therapy was uncommon (4%). More than half of patients switched regimens within 1 year, mostly as the planned duration ended (71%) or following an outcome event (12%). During follow-up (median 68 days [IQR, 28-120]), 21 patients (11%) had recurrent ischemic stroke, and 26 (14%) had symptomatic hemorrhage, over half of each within 90 days; 25% of deaths occurred within 90 days. Ninety-day stroke/death rate was 24%, with single anticoagulant versus 8% with single anticoagulant+sAP; symptomatic hemorrhage rate was 0% and 12%, respectively. At 1 year, stroke/death was 27.3% with sAP, 11.1% with single anticoagulant+sAP, 4.5% with single anticoagulant, and 0% with dual antiplatelet therapy. Symptomatic hemorrhage was similar across groups. CONCLUSIONS: In patients with atrial fibrillation and symptomatic large-artery atherosclerosis, recurrent ischemic events and mortality were common, and antithrombotic management varied substantially. The combination of single anticoagulant+sAP was associated with lower observed short-term stroke/death than single anticoagulant; however, bleeding remains a concern with prolonged therapy. Prospective studies are needed to define optimal regimen and duration for this high-risk population.
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BibTeX
@article{mohamed2026antithrombotic,
title = {{Antithrombotic Therapy for Secondary Stroke Prevention in Patients With Symptomatic Large‐Artery Atherosclerosis and Atrial Fibrillation: A Multicenter Experience}},
author = {Ghada A. Mohamed and Adam de Havenon and Renee H. Martin and Fadi Nahab and Tareq Kasshout and Ahmad Abu Qdais and McKay Hanna and Evangelos Pavlos Myesrlis and Neeharika Krothapalli and Michael Liu and Tanya N. Turan},
journal = {Journal of the American Heart Association},
year = {2026},
month = oct,
doi = {10.1161/jaha.126.050008},
url = {https://www.ahajournals.org/doi/10.1161/JAHA.126.050008},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Antithrombotic Therapy for Secondary Stroke Prevention in Patients With Symptomatic Large‐Artery Atherosclerosis and Atrial Fibrillation: A Multicenter Experience
AU - Ghada A. Mohamed
AU - Adam de Havenon
AU - Renee H. Martin
AU - Fadi Nahab
AU - Tareq Kasshout
AU - Ahmad Abu Qdais
AU - McKay Hanna
AU - Evangelos Pavlos Myesrlis
AU - Neeharika Krothapalli
AU - Michael Liu
AU - Tanya N. Turan
PY - 2026
DA - 2026/10/20
JO - Journal of the American Heart Association
DO - 10.1161/jaha.126.050008
UR - https://www.ahajournals.org/doi/10.1161/JAHA.126.050008
AB - BACKGROUND: Optimal antithrombotic therapy for ischemic stroke due to symptomatic large-artery atherosclerosis in patients with atrial fibrillation remains uncertain. We describe real-world prescribing patterns and outcomes across antithrombotic regimens. METHODS: We retrospectively analyzed consecutive patients with atrial fibrillation and ischemic stroke related to symptomatic large-artery atherosclerosis (intracranial or extracranial or both) at 4 US comprehensive stroke centers. Patients were grouped by discharge regimen: single anticoagulant, single antiplatelet (sAP), single anticoagulant+sAP, dual antiplatelet therapy, or triple therapy (single anticoagulant+dual antiplatelet therapy). Outcomes were recurrent ischemic stroke, symptomatic hemorrhage, and death at 90 days and 1 year. RESULTS: Among 191 patients (median age 75 years [interquartile range [IQR], 68-83]; 40% women; 36% prior stroke/transient ischemic attack), single anticoagulant+sAP was the most common discharge regimen (33%), followed by single anticoagulant (25%), whereas triple therapy was uncommon (4%). More than half of patients switched regimens within 1 year, mostly as the planned duration ended (71%) or following an outcome event (12%). During follow-up (median 68 days [IQR, 28-120]), 21 patients (11%) had recurrent ischemic stroke, and 26 (14%) had symptomatic hemorrhage, over half of each within 90 days; 25% of deaths occurred within 90 days. Ninety-day stroke/death rate was 24%, with single anticoagulant versus 8% with single anticoagulant+sAP; symptomatic hemorrhage rate was 0% and 12%, respectively. At 1 year, stroke/death was 27.3% with sAP, 11.1% with single anticoagulant+sAP, 4.5% with single anticoagulant, and 0% with dual antiplatelet therapy. Symptomatic hemorrhage was similar across groups. CONCLUSIONS: In patients with atrial fibrillation and symptomatic large-artery atherosclerosis, recurrent ischemic events and mortality were common, and antithrombotic management varied substantially. The combination of single anticoagulant+sAP was associated with lower observed short-term stroke/death than single anticoagulant; however, bleeding remains a concern with prolonged therapy. Prospective studies are needed to define optimal regimen and duration for this high-risk population.
SN - 2047-9980
ER -