ISC 2024 | Assessing risk in patients with breakthrough stroke in atrial fibrillation
Valeria Caso, MD, PhD, FESO, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy, discusses key factors when assessing risk in patients with atrial fibrillation (AF) who experience ischemic stroke despite oral anticoagulation. Breakthrough strokes are not uncommon and identify an important patient subgroup at high risk of stroke recurrence and mortality. Prof. Caso notes the importance of shedding light on the mechanism underlying anticoagulation failure in order to implement preventive measures. For example, insufficient OAC is seen in almost one-third of AF patients with stroke despite OAC. Additionally, around 30% of strokes due to OAC failure may be attributed to competing non-cardioembolic mechanisms. The third category, cardioembolic stroke despite adequate OAC, represents a more challenging clinical scenario. Prof. Caso discusses the need for a detailed global risk assessment of the patient to identify areas for intervention. This interview took place during the International Stroke Conference 2024 in Phoenix, AZ.
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Transcript (edited for clarity)
Regarding residual risk in atrial fibrillation, I think this is a very important topic because it’s the typical what we call the ‘failure’. Patients think she or he is safe or treatment, everything is going well and then we realize that he or she is coming to us with a stroke. So what we try to understand first is if there is really an adherence, because sometimes they tell you “oh yes, I took the drug” and then you discover that they took the drug, which was supposed to be taken twice daily, only once daily...
Regarding residual risk in atrial fibrillation, I think this is a very important topic because it’s the typical what we call the ‘failure’. Patients think she or he is safe or treatment, everything is going well and then we realize that he or she is coming to us with a stroke. So what we try to understand first is if there is really an adherence, because sometimes they tell you “oh yes, I took the drug” and then you discover that they took the drug, which was supposed to be taken twice daily, only once daily. So then, okay, here we have a reason. And then if not, if everything is perfect, they adhere and so on, then you look at the pattern of the stroke. For example, 30% of these patients have not cardioembolic stroke. So you have to evaluate the global risk profile of these patients, because if they have, for example, lacunar stroke, then you have to think about not well controlled hypertension. Or sometimes these patients have dyslipidemia, diabetes. And for example now we see a lot of new treatment options in diabetes and hyperlipidemia that we didn’t have in the past so we can propose them as better treatments. Or sometimes you see it’s a pattern of a cardioembolic stroke and then you have to think how to optimize better the treatment.
The workup is, is first of all you have the imaging. You see that this patient had a stroke. And then as I said before, you look at the pattern of the stroke, you distinguish if you have a typical cortical stroke. And then sometimes you evidence this by CT or even better by MRI because you can see also different spots, especially if there is embolization. And then this is for the imaging and let’s say the impact pattern. And then you do all the workup because you have to re-control the carotid because maybe this patient had 50% of carotid stenosis and in the meantime this carotid plaque grew and now they need to be operated. Sometimes with some valves which do not need operation, but they can have some infections. So you have to look, if there are any kind of endocarditis, you have to look at the blood examination. As I said before, you have to look at the lipid profile, sugar profile. So it’s a lot of workup that you should do, such as doing a workup for first cardioembolic stroke.
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