Put your finger down if…

Your patient comes into the clinic complaining about their heart racing…
Textbook History.

ECG: irregularly irregular. Atrial fibrillation. No problem.

You rhythm-control them. You CHA₂DS₂-VASc them up. They need anticoagulation.

You skip the Warfarin because… come on.

You avoid the Rivaroxaban because you read The Handover last week.

You land on Apixaban.

They’re stable. They’re happy. Just another day as your friendly neighbourhood GP 😏

Your patient suffers an ischaemic stroke 24 hours later.

Yeah… Even among patients optimally anticoagulated, strokes can still happen. And if they do recur, what the hell do we do about it? Because the instinct is immediate: “The DOAC didn’t work. So what's the next step?

Switch to ye’ olde’ warfarin?

Switch to a different DOAC?

Change dosage of the current DOAC?

Add an antiplatelet to the DOAC?

Hmmmm 🤔Good Question!

Let’s see if this meta-analysis can answer that.

Published in , this study set out to compare the effectiveness and safety of these anticoagulation strategies in patients who had an ischaemic stroke despite already being on a DOAC.
(Yes, it’s a long sentence. No, it doesn’t get better the second time.)

Looking specifically for the occurrence of recurrent ischaemic stroke, intracranial haemorrhage (ICH), any stroke, and all-cause mortality across the studies chosen.

After toiling, perusing and filtering, they settled on 8 observational studies that included a total of 14,307 patients who fit the bill(met the inclusion criteria).

So… what's the right answer?

Don’t Switch to Warfarin: Outside of metallic valves, warfarin is never the right answer. Never. It carried an 80% higher risk of recurrent ischaemic stroke (RR 1.80, 95% CI 1.42–2.29) and nearly triple the intracranial haemorrhage risk (RR 2.90, 95% CI 2.01–4.18) versus staying on the same DOAC.

DOAC vs DOAC: If you do switch across DOACs, there is… no significant difference (RR 0.95, 95% CI 0.73–1.24). Use your better judgment.

Antiplatelet Antidote?: Nope. Adding an antiplatelet here provided no benefit. In fact, it may have even been harmful with trends toward more recurrent strokes compared to DOAC alone (RR 0.76, 95% CI 0.56–1.02), narrowly missing significance.

Mortality: Mortality is pretty consistent across groups… wait. Of course, warfarin significantly increased mortality risk versus all other strategies. A 47% higher risk of death compared to DOAC plus antiplatelet (RR 1.47, 95% CI 1.09–2.00).

Whilst this meta-analysis does have its shortcomings (no RCT data, just 8 studies, and study design differences). The study authors leave with this

"Checking for adherence issues, inappropriate dosage, pharmacologic interactions, and whether the stroke was truly attributable to AF rather than another competing etiology seems paramount."

I personally leave with this: Don’t touch that Warfarin.