Residual Risk of Ischemic Stroke Despite Anticoagulation in Patients Hospitalized with Atrial Fibrillation: Insights from the Get with the Guidelines-Atrial Fibrillation Program

Presenter: Brototo Deb.

Oral anticoagulation (OAC) lowers stroke risk in atrial fibrillation (AF), yet residual risk persists among treated patients, and contemporary real-world data on that risk and on long-term adherence are limited. Using the Get With The Guidelines-Atrial Fibrillation (GWTG-AFIB) registry linked to Medicare claims (2017-2023), investigators followed patients aged ≥65 years discharged on OAC after an AF hospitalisation for 3 years. Among 15,873 patients (mean age 76 years; 55.8% female), 405 (2.6%) had ischemic stroke/systemic embolism (incidence 11.9 per 1000 person-years) and all-cause mortality was 28.7%. Independent predictors of stroke were age (adjusted hazard ratio [aHR] 1.22 [1.14-1.30] per 5 years), prior stroke/transient ischemic attack (aHR 1.67 [1.22, 2.27]), diabetes (aHR 1.48 [1.20, 1.84]) and GARFIELD (stroke and systemic embolism) risk >2 (aHR 1.52 [1.11, 2.09]). OAC adherence remained 50-55% across all 6-month intervals through 3 years. Residual stroke risk thus persists despite OAC at discharge, driven by clinical risk factors rather than treatment gaps alone, with suboptimal long-term adherence; the authors call for better risk stratification and strategies to sustain anticoagulation and adjunctive therapies.

Not all Factor Xa Inhibitors are Equal: Apixaban a Better Choice than Rivaroxaban for Stroke Prevention in Atrial Fibrillation Patients: Evidence from a Meta-Analysis

Presenter: Venkata Sai Abhilash Meda.

Real-world comparative effectiveness of apixaban and rivaroxaban in non-valvular atrial fibrillation (NVAF) remains incompletely defined, and no dedicated randomised controlled trial (RCT) has compared them. This meta-analysis pooled propensity-matched populations from 13 studies (2015-2025) comprising 1,013,094 patients (apixaban: n = 537,030; rivaroxaban: n = 476,064). Across 11 studies (n=967,367), apixaban was associated with lower ischemic stroke risk (odds ratio [OR] 0.85 [95% confidence interval (CI) 0.82-0.87], p<0.00001), though with substantial heterogeneity (I2=98%). Hemorrhagic stroke did not differ across 4 studies (n=627,699; OR 0.97 [95% CI 0.88-1.07], p=0.55). Across 12 studies (n=1,013,094), overall bleeding risk was lower with apixaban (OR 0.61 [95% CI 0.60-0.63], p<0.00001). As indirect comparative evidence, these data favour apixaban for ischemic stroke and bleeding with comparable hemorrhagic stroke rates; the authors suggest they may guide clinical decision-making pending future RCTs.

Comparative Safety and Effectiveness of DOACs versus Warfarin in AF with Chronic Kidney Disease: A Propensity Score Matched Retrospective Study

Presenter: Shahzeb Saeed.

Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) face elevated thromboembolic and bleeding risk, were underrepresented in landmark trials, and have limited real-world comparisons of direct oral anticoagulants (DOACs) with warfarin. In this TriNetX cohort, adults with AF and CKD initiating a DOAC or warfarin were propensity matched 1:1 (62,565 per group) and followed for 365 days. DOAC therapy was associated with lower all-cause mortality (12.7% vs 15.3%; risk ratio [RR] 0.83, 95% confidence interval [CI] 0.81-0.85), intracranial hemorrhage (1.5% vs 2.2%; RR 0.68), major bleeding (9.3% vs 10.3%; RR 0.93) and inpatient hospitalisation (30.9% vs 32.4%; RR 0.95), but higher gastrointestinal bleeding (6.0% vs 5.5%; RR 1.09). Ischemic stroke (RR 1.04; P=0.378), acute kidney injury and acute myocardial infarction did not differ. These findings support DOACs as an anticoagulation option in AF with CKD, warranting prospective confirmation.

Direct Oral Anticoagulants versus Warfarin in Lead-Related Venous Obstruction after Cardiac Implantable Electronic Device Implantation

Presenter: Yong Hao Yeo.

Lead-related venous obstruction (LRVO) is a recognised complication of cardiac implantable electronic device (CIED) placement, and comparative data on direct oral anticoagulants (DOACs) versus warfarin for symptomatic LRVO are limited. Using TriNetX, investigators identified 4,943 adults with symptomatic LRVO after first-time CIED implantation (DOAC: 3,531 [71.4%]; warfarin: 1,412 [28.6%]) and compared 5-year outcomes in 1,354 propensity-matched patients per group. DOAC therapy was associated with lower risks of major bleeding (13.4% vs 21.9%, P<0.01) and CIED removal (2.3% vs 3.8%, P=0.03), while pulmonary embolism (PE) (8.1% vs 8.2%, P=0.89) and all-cause hospitalisation (60.0% vs 62.3%, P=0.22) were similar. Outcomes did not differ significantly between apixaban and rivaroxaban, or between single- and dual-lead pacemaker recipients treated with DOACs. In symptomatic LRVO, DOACs were thus linked to less bleeding and fewer device removals than warfarin, without differences in PE or hospitalisation.

American Heart Association (AHA) Scientific Sessions 2026, November 6–9, Chicago, Illinois