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Cardiac Tumors and Thrombi · Journal article
Journal of Neurology · August 17, 2026
Encouraging direction, but not yet definitive.
This multicenter retrospective study of 1649 patients with ischemic stroke despite ongoing oral anticoagulation found that identifiable potential causes (drug interactions, cancer, competing etiologies) were present in 43.9% of cases. Patients with ≥1 potential cause had higher 90-day recurrent ischemic stroke risk (HR 2.04, 95% CI 1.18–3.53), and drug interactions were associated with increased myocardial infarction risk (HR 3.26, 95% CI 1.30–8.17) in inverse probability-weighted analysis.
Multicenter, retrospective cohort study. Patients aged ≥18 years with acute ischemic stroke occurring despite ongoing oral anticoagulation (DOAC or VKA) for atrial fibrillation, enrolled across multiple centers February 2020–February 2025. Setting: hospital-based acute stroke services.. Intervention: Identification and categorization of potential causes: interacting drugs, competing etiologies, active cancer. Compared with: Patients without identifiable potential causes. n = 1,649. Multicenter study; specific countries and number of centers not stated in abstract.
Among 1649 patients (median age 80.4 years, 52.2% female), 724 (43.9%) had ≥1 potential cause of breakthrough stroke Interacting drugs identified in 28.4%, competing etiologies in 24.3%, and cancer in 4.4% of cases Patients with ≥1 potential cause had HR 2.04 (95% CI 1.18–3.53) for recurrent ischemic stroke at 90 days
Safety was not reported in the material analysed. Check the source before drawing any conclusion about harm.
Clinicians managing breakthrough ischemic stroke in anticoagulated patients should systematically screen for drug interactions, competing stroke etiologies, and occult malignancy, as these factors are present in ~44% of cases and are associated with higher recurrence risk. The identification and management of these modifiable causes may reduce secondary stroke risk in this high-risk population.
Retrospective multicenter study identifying modifiable causes in breakthrough stroke despite anticoagulation, with adjusted hazard ratios for recurrence and myocardial infarction, but limited by observational design and surrogate clinical outcomes rather than definitive practice-changing evidence.
As stated by the source record.
Quoted from the source exactly as published.
Clinicians managing breakthrough ischemic stroke in anticoagulated patients should systematically screen for drug interactions, competing stroke etiologies, and occult malignancy, as these factors are present in ~44% of cases and are associated with higher recurrence risk. The identification and management of these modifiable causes may reduce secondary stroke risk in this high-risk population.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
BACKGROUND: Oral anticoagulants (OACs), including vitamin K antagonists and direct OACs, reduce stroke risk in atrial fibrillation (AF), yet breakthrough ischemic stroke still occurs in 1-2% of patients annually despite adequate therapy. The mechanisms underlying these events remain unclear. We aimed to identify potential causes of breakthrough ischemic stroke and assess their impact on outcomes, with a focus on drug interactions. METHODS: ASPERA-R is a multicenter retrospective study including patients with ischemic stroke despite ongoing OAC therapy for AF (February 2020-February 2025). Ongoing treatment was defined by DOAC last intake within 48 h or therapeutic INR levels for VKAs. Potential causes included interacting drugs, active cancer, and competing etiologies. Ninety-day outcomes were compared between patients with and without ≥ 1 potential cause using adjusted Cox regression. Inverse probability-weighted analyses (IPW) evaluated the impact of interacting drugs. RESULTS: Among 1649 patients (median age 80.4 years [IQR 73.2-85.6]; 860 [52.2%] female), most were on DOACs (1275; 77.3%), and 724 (43.9%) had ≥ 1 potential cause. Interacting drugs were identified in 28.4%, competing etiologies in 24.3%, and cancer in 4.4% cases. Patients with one or more potential cause had a higher risk of recurrent ischemic stroke at 90 days (HR 2.04, 95% CI 1.18-3.53) compared with those without, with no differences in other outcomes. In the IPW analyses, interacting drugs were associated with increased myocardial infarction risk (HR 3.26, 95% CI 1.30-8.17). CONCLUSIONS: Potential causes are identifiable in about half of breakthrough strokes and are associated with higher risk of recurrence compared with those without. Improved detection and management of these factors may reduce recurrence risk, warranting individualized approaches.
Taken from the source record, never inferred. Follow any of these and new work involving them reaches your briefing.