Highlights
- •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.
Abstract
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).
Methods
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).
Results
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.
Conclusions
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
Graphical Abstract
Keywords
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Article info
Publication history
Published online: January 24, 2019
Accepted:
January 10,
2019
Received in revised form:
November 20,
2018
Received:
June 14,
2018
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
