Secondary prevention after breakthrough stroke in atrial fibrillation: emerging evidence

Valeria Caso, MD, PhD, FESO, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy, discusses recent advances in the prevention of ischemic stroke recurrence in patients with atrial fibrillation with breakthrough stroke. There are numerous mechanisms known to underlie breakthrough stroke, including insufficient anti-coagulation and competing non-cardioembolic mechanisms. However, cardioembolic strokes can still occur in patients with atrial fibrillation under adequate anticoagulation in the absence of competing stroke mechanisms and in these cases, the underlying factors at play are not clear. Improvement of cardiovascular risk factor control is important in this setting. Switching the oral anticoagulant is a common strategy in these patients, but recent data from the RENO-EXTEND study showed that this was not associated with reduced ischemic events. Similarly, the addition of antiplatelet therapy was associated with increased ischemic and bleeding risk in this study. Left atrial appendage closure is emerging as a potentially beneficial add-on strategy, with data from LAAOS III (NCT01561651) showing a reduction in recurrent stroke risk when used with oral anticoagulation. More data is required on these strategies in order to provide specific recommendations about the optimal approach. This interview took place during the International Stroke Conference 2024 in Phoenix, AZ.

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