Abstract Number: Esoc2026a679 Continuation Versus Switching Direct Oral Anticoagulant After Breakthrough Stroke: a Non-inferiority Target Trial Analysis From the Aspera-r Study
Year: 2026
Type: conference-abstract
Abstract: Background and aims Management strategies after ischemic stroke occurring despite direct oral anticoagulant (DOAC) therapy for atrial fibrillation vary widely, and switching anticoagulation is common despite limited supporting evidence. We compared the effectiveness and safety of continuing the same DOAC versus switching to another oral anticoagulant after a breakthrough stroke using a prespecified non-inferiority framework. Methods We conducted an emulated target trial within a non-inferiority framework to compare continuation versus switching anticoagulation strategies using data from the multicentre, retrospective ASPERA registry. Adult patients with atrial fibrillation who experienced a breakthrough ischemic stroke while receiving uninterrupted DOAC therapy were included. The primary outcome was 90-day net clinical benefit, defined as the composite of recurrent ischemic stroke and moderate-to-severe bleeding; secondary outcomes included recurrent ischemic events, symptomatic intracranial haemorrhage, all-cause and vascular mortality. Baseline confounding was addressed using inverse probability of treatment weighting (IPTW). Results Overall, 1006 patients were included (median age 80.4 years [IQR 73.4–85.4]; 50% women). DOAC therapy was continued in 463 patients and switched to another DOAC or vitamin K antagonist in 543. After IPTW adjustment, 90-day net clinical benefit was similar between strategies (5.1% vs 4.9%), with a risk difference of −0.3% (90% CI −2.7% to 2.1%), meeting the non-inferiority criterion. Secondary outcomes were comparable, whereas non-inferiority was not demonstrated for all-cause or vascular mortality. Conclusions In this multinational emulated target trial, continuation of the same DOAC after breakthrough stroke was associated with clinical outcomes comparable to switching anticoagulant therapy, with absolute differences remaining within clinically acceptable margins for most outcomes. Conflict of interest nothing to disclose
Source: European Stroke Journal
Authors: Lucio D'anna, Matteo Foschi, Federico De Santis, Francesca Gabriele, Andrea Zini, Angelo Cascio Rizzo, Leonardo Pantoni, Giovanni Merlino, Barbara Casolla, Blanca Fuentes, Paolo Candelaresi, Diana Aguiar de Sousa, Ahmed Abdelalim, Liqun Zhang, Pietro Caliandro, Giovanni Frisullo, Maria Rosaria Bagnato, Giuseppe Rinaldi, Raffaele Ornello, Simona Sacco
Institutions: Imperial College London, University of L'Aquila, Istituto delle Scienze Neurologiche di Bologna, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, University of Milan, University of Udine, Université Côte d'Azur, Hôpital Pasteur, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research, Ospedale Antonio Cardarelli, University of Lisbon, Cairo University, Cairo University hospitals, St George's Hospital, St George's, University of London, Università Cattolica del Sacro Cuore, Agostino Gemelli University Polyclinic, Istituti di Ricovero e Cura a Carattere Scientifico, Universitat Oberta de Catalunya
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,400
OpenAlex ID: W7160428333
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