OBJECTIVES:This study aimed to investigate the outcomes and effectiveness of different antithrombotic regimens at discharge in nonvalvular atrial fibrillation (NVAF) patients with acute ischemic stroke (AIS) and competing large artery atherosclerosis (LAA) mechanisms. METHODS:In an observational study, we retrospectively analyzed the clinical and follow-up data of NVAF patients with AIS from January 2018 to December 2021 (NCT04080830). The subjects were grouped into 2 groups based on the presence or absence of competing LAA mechanisms. Stroke severity, short-term prognosis, and ischemic recurrence (a composite of ischemic stroke/TIA, myocardial infarction, or systemic embolism after index stroke), were compared between the 2 groups. Antithrombotic regimens at discharge were further categorized into antiplatelet and anticoagulant subgroups to analyze their effectiveness. RESULTS:Five hundred-one NVAF patients with AIS (129 with and 372 without competing LAA mechanisms) were included. Compared with the other group, the group with competing LAA mechanisms had a higher proportion of patients with a nondisabling mRS score (P <0.001), lower mortality rates at the 90-day follow-up ( P =0.048), and higher 180-day ischemic outcomes ( P =0.023). Subgroup analysis showed that the ischemic outcomes were not significantly different ( P =0.166) between the anticoagulant and antiplatelet subgroups in patients with competing LAA mechanisms. In contrast, it was numerically higher in the anticoagulant subgroup. CONCLUSION:NVAF patients with AIS due to competing LAA mechanisms had mild severity and a comfortable short-term prognosis; however, these patients had a higher risk of ischemic events. The optimal antithrombotic regimens in these patients remain unclear, and stroke mechanisms should be considered.

目的 探讨既往接受口服抗凝治疗的非瓣膜性心房颤动(NVAF)患者发生急性缺血性卒中(AIS)的临床特征.方法 回顾性分析单中心患者登记研究(NCT04080830)中2016年1月至2021年12月在首都医科大学宣武医院神经内科住院的合并NVAF的AIS患者数据,根据发病前抗凝状态将患者分为未抗凝组、充分抗凝组和抗凝不足组,比较3组患者的临床特征.结果 共纳入749例合并NVAF的AIS患者,其中未抗凝组661例,充分抗凝组33例,抗凝不足组55例.充分抗凝组出现大面积脑梗死的比例、初始和出院时的美国国家卫生研究院卒中量表评分均低于未抗凝组[15.2%(5/33)比34.2%(226/666)、4.00(1.00,7.50)分比8.00(3.00,15.00)分、2.00(0,5.00)分比4.00(1.00,12.00)分],出院时改良Rankin量表评分≤2分的比例高于未抗凝组[66.7%(22/33)比44.0%(226/666)],差异均有统计学意义(均P＜0.05).充分抗凝组和抗凝不足组的静脉溶栓比例低于未抗凝组[3.0%(1/33)、3.6%(2/55)比5.6%(37/666)],差异有统计学意义(P＜0.01).充分抗凝组存在心源性/大动脉粥样硬化性卒中型的AIS病因的患者比例高于未抗凝组和抗凝不足组[42.4%(14/33)比21.8%(144/666)、16.4%(9/55)],差异有统计学意义(P＜0.01).结论 既往充分抗凝治疗与NVAF患者发生AIS后卒中严重程度较低和出院时功能预后较好相关,竞争性大动脉动脉粥样硬化性AIS发生机制可能是充分抗凝治疗未能有效防控NVAF患者AIS风险的原因之一.

Objectives: We aimed to analyze the characteristics and mechanisms of acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) who received prior anticoagulant therapy. Methods: We retrospectively analyzed the data of patients with NVAF and AIS between January 2016 and December 2021. Patients were divided into non-anticoagulant, adequate anticoagulant, and insufficient anticoagulant groups according to their prior anticoagulant status. Patients with prior anticoagulant therapy were further divided into warfarin and direct oral anticoagulant groups. Results: A total of 749 patients (661 without anticoagulants, 33 with adequate anticoagulants, and 55 with insufficient anticoagulants) were included. Patients with adequate anticoagulant had a milder National Institute of Health Stroke Scale at presentation (P=0.001) and discharge (P=0.003), a higher proportion of Modified Rankin Scale (mRS) ≤2 at discharge (P=0.011), and lower rates of massive infarction (P=0.008) than patients without anticoagulant. Compared with the non-anticoagulant group, the proportion of intravenous thrombolysis was significantly lower in the adequate anticoagulant (P<0.001) and insufficient anticoagulant (P=0.009) groups. Patients in the adequate anticoagulant group had higher rates of responsible cerebral atherosclerotic stenosis (P=0.001 and 0.006, respectively) and competing large artery atherosclerotic mechanisms (P=0.006 and 0.009, respectively) than those in the other 2 groups. Compared with warfarin, direct oral anticoagulant was associated with higher rates of Modified Rankin Scale ≤2 at discharge (P=0.003). Conclusions: Adequate anticoagulant therapy may be associated with milder stroke severity and better outcomes at discharge in patients with NVAF. Competing large artery atherosclerotic mechanisms may be associated with anticoagulant failure in patients with NAVF with prior adequate anticoagulant therapy.