Oral Anticoagulants in the Oldest Old with Recent Stroke and Atrial Fibrillation
Alexandros A. Polymeris, Kosmas Macha, Maurizio Paciaroni, Duncan Wilson, Masatoshi Koga, Manuel Cappellari, Sabine Schaedelin, Annaelle Zietz, Nils Peters, David Seiffge, David Haupenthal, Luise Gaßmann, Gian Marco De Marchis, Ruihao Wang, Henrik Gensicke, Svenja Stoll, Sebastian Thilemann, Nikolaos S. Avramiotis, Bruno Bonetti, Georgios Tsivgoulis, Gareth Ambler, Andrea Alberti, Sohei Yoshimura, Martin M. Brown, Masayuki Shiozawa, Gregory Y.H. Lip, Michele Venti, Monica Acciarresi, Kanta Tanaka, Maria Giulia Mosconi, Masahito Takagi, Hans Rolf Jäger, Keith W. Muir, Manabu Inoue, Stefan Schwab, Leo H. Bonati, Philippe Lyrer, Ḱazunori Toyoda, Valeria Caso, David J. Werring, Bernd Kallmünzer, Stefan T. Engelter, NOACISP‐LONGTERM, Erlangen Registry, CROMIS‐2, RAF, RAF‐DOAC, SAMURAI‐NVAF and Verona Registry Collaborators
Abstract
Objective To investigate the safety and effectiveness of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) after recent stroke in patients with atrial fibrillation (AF) aged ≥85 years. Methods Individual patient data analysis from seven prospective stroke cohorts. We compared DOAC versus VKA treatment among patients with AF and recent stroke (<3 months) aged ≥85 versus <85 years. Primary outcome was the composite of recurrent stroke, intracranial hemorrhage (ICH) and all‐cause death. We used simple, adjusted, and weighted Cox regression to account for confounders. We calculated the net benefit of DOAC versus VKA by balancing stroke reduction against the weighted ICH risk. Results In total, 5,984 of 6,267 (95.5%) patients were eligible for analysis. Of those, 1,380 (23%) were aged ≥85 years and 3,688 (62%) received a DOAC. During 6,874 patient‐years follow‐up, the impact of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome did not differ between patients aged ≥85 (HR ≥85y = 0.65, 95%‐CI [0.52, 0.81]) and < 85 years (HR <85y = 0.79, 95%‐CI [0.66, 0.95]) in simple (p interaction = 0.129), adjusted (p interaction = 0.094) or weighted (p interaction = 0.512) models. Analyses on recurrent stroke, ICH and death separately were consistent with the primary analysis, as were sensitivity analyses using age dichotomized at 90 years and as a continuous variable. DOAC had a similar net clinical benefit in patients aged ≥85 (+1.73 to +2.66) and < 85 years (+1.90 to +3.36 events/100 patient‐years for ICH‐weights 1.5 to 3.1). Interpretation The favorable profile of DOAC over VKA in patients with AF and recent stroke was maintained in the oldest old. ANN NEUROL 2022;91:78–88