In patients with atrial fibrillation (AFib) experiencing a breakthrough ischemic stroke while on a direct oral anticoagulant (DOAC) regimen, switching to a different DOAC was noninferior to continuing the same DOAC, according to a study published April 28 in JAMA Network Open.

In their study, Lucio D'Anna, MD, PhD, et al., included 1,006 patients (median age 80.4 years, 50% female) − 46% continuing the same DOAC therapy and 54% making up the intervention group that switched therapy. The primary outcome was net clinical benefit at 90 days, looking at recurrent ischemic stroke and moderate to severe bleeding.

After adjustment, D'Anna and colleagues found the 90-day net clinical benefit was 4.9% for those who switched and 5.1% for those who continued their current DOAC therapy. These results confirm that switching DOAC therapy was noninferior to continuation, with a risk difference between the two groups of −0.3 percentage points (90% CI, −2.7 to 2.1 percentage points).

The authors also note that absolute differences were within prespecified noninferiority margins for recurrent ischemic events and bleeding outcomes; however, the analysis did not show noninferiority for all-cause or vascular mortality.

"Our results challenge the empirical practice of switching anticoagulants after a breakthrough stroke," state the authors. "When poor adherence, inappropriate dosing and alternative stroke mechanisms have been ruled out, continuation of the same DOAC may represent a safer and simpler strategy, avoiding the transient loss of anticoagulation protection, dosing errors and uncertainty associated with switching."