JAMA Netw Open
Switching DOACs after breakthrough stroke shows no short‑term advantage
Clinical takeaway: In patients with atrial fibrillation who experience an ischemic stroke while taking a DOAC, routinely switching anticoagulants didn't improve 90‑day net clinical outcomes compared with continuing the same agent. Focus evaluation on adherence, interactions, dosing, and stroke mechanism before changing therapy.
Breakthrough ischemic stroke despite direct oral anticoagulant (DOAC) therapy remains a management gray zone, and switching agents is common in practice despite limited data to support benefit.
In this multicenter, registry‑based cohort study emulating a target trial, investigators followed 1,006 adults with atrial fibrillation who had an ischemic stroke while receiving uninterrupted DOAC therapy and subsequently resumed anticoagulation. Overall, 463 patients (46%) continued their prestroke DOAC, while 543 (54%) switched to a different DOAC or to a vitamin K antagonist. Median age was 80 years, and follow‑up was standardized at 90 days.
After inverse probability weighting, the primary outcome—90‑day net clinical benefit (recurrent ischemic stroke or moderate‑to‑severe bleeding)—occurred in 5.1% of patients who continued therapy and 4.9% of those who switched (risk difference −0.3 percentage points), meeting prespecified criteria for noninferiority. Absolute differences in recurrent ischemic events and major bleeding were small and clinically similar between strategies. Noninferiority wasn't demonstrated for all‑cause or vascular mortality, highlighting ongoing uncertainty for longer‑term outcomes.
These findings suggest that switching anticoagulants after breakthrough stroke should be individualized rather than automatic.
Source: D’Anna L, et al. (2026, April 28). JAMA Netw Open. Continuation vs Switching Direct Oral Anticoagulant Therapy After Breakthrough Stroke