Research Article| Volume 283, P13-18, April 2019

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Stroke occurrence while on antiplatelet therapy may predict atrial fibrillation detected after stroke

  • Cheng-Yang Hsieh
    Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan

    School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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  • Cheng-Han Lee
    Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
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  • Sheng-Feng Sung
    Corresponding author. Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, 539 Zhongxiao Road, East District, Chiayi City 60002, Taiwan.
    Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan

    Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan
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      • A breakthrough stroke is an ischemic stroke despite treatment with antiplatelets.
      • Early detection of atrial fibrillation (AF) is essential in stroke patients without known AF.
      • A breakthrough stroke of mild severity may predict AF detected after stroke.
      • Patients with a breakthrough stroke are recommended for cardiac monitoring.


      Background and aims

      Stroke occurrence while on antiplatelet therapy, i.e., a breakthrough stroke, is often conveniently attributed to antiplatelet resistance. However, undetected paroxysmal atrial fibrillation (AF) may underlie breakthrough strokes. We hypothesized that a breakthrough stroke may be a clinical marker for patients at risk of having AF detected after stroke (AFDAS).


      Consecutive patients without known AF hospitalized for ischemic stroke between 2000 and 2013 were identified from nationwide claims data. The independent variable of interest was continued use of antiplatelet therapy within 30 days before stroke. The diagnosis of AF and comorbidities were ascertained using validated algorithms. Stroke severity (National Institutes of Health Stroke Scale [NIHSS]) was estimated using a validated claims-based method. Univariable and multivariable Cox regression analyses were used to determine the effect of breakthrough strokes on the occurrence of AFDAS separately in patients with mild and severe stroke (estimated NIHSS ≤10 versus >10).


      Among 17,076 patients (40% female, mean age 69 years), 3314 (19%) were on antiplatelet therapy before stroke. In patients with mild stroke, prior antiplatelet use was significantly associated with the occurrence of AFDAS (adjusted hazards ratio, 1.26; 95% confidence interval, 1.08–1.48). In contrast, no association existed between prior antiplatelet use and the risk of AFDAS in those with severe stroke.


      Patients with a breakthrough stroke of mild severity while on antiplatelet therapy carried an increased risk of AFDAS compared to those not on antiplatelet therapy. Our findings may help prioritize patients for advanced cardiac monitoring in daily practice.

      Graphical abstract


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