Managing Ischemic Stroke in Patients Already on Anticoagulation for Atrial Fibrillation: A Nationwide Practice Survey

Background and purpose: We sought to understand practice patterns in management of patients who have ischemic stroke while adherent to oral anticoagulation for non-valvular atrial fibrillation (NVAF) in the United States (US). Methods: We distributed an iteratively revised online survey to US neurologists in May-June 2019. Survey questions focused on clinicians' practices regarding diagnostic evaluation and secondary prevention after ischemic stroke in patients already on oral anticoagulation for NVAF. Standard descriptive statistics were used to summarize participants' characteristics and responses. Results: Of the 120 participating clinicians, 79% were attending physicians. Most respondents (66%) were trained in vascular neurology, and 79% were employed in hospital-based, academic settings. For patients with ischemic stroke despite anticoagulation, most respondents indicated that they obtain extracranial and intracranial vessel imaging (72% and 82%, respectively). Most respondents (83%) routinely change therapy to a direct oral anticoagulant (DOAC) for patients experiencing ischemic stroke while on warfarin. In cases of ischemic stroke while on a DOAC, 38% of respondents routinely switch agents, 42% do not routinely switch agents, and 20% routinely add an antiplatelet agent. In this scenario, 83% of respondents who switch agents indicated that the reason was a possible better response to a drug that acts through a different mechanism. The most common reason for not switching while on a DOAC was the lack of randomized trial data. Conclusions: There is a high degree of variability in practice patterns among US neurologists caring for patients with ischemic stroke while already on oral anticoagulation for NVAF.