Real-world use and impact of direct oral anticoagulants among atrial fibrillation patients with cardioembolic stroke

Background and aims – Atrial fibrillation (AF) is a primary cause of cardioembolic stroke (CES). Non-adherence to direct oral anticoagulants (DOACs) remains a major health policy issue. This study aimed to investigate real-world DOAC usage among AF patients presenting with stroke and to evaluate the impact of prior DOAC therapy on stroke severity. Methods – This retrospective study analyzed data on DOAC usage from CES patients with AF admitted to the two largest Latvian university hospitals between January 2022 and December 2024. We further compared patients’ characteristics receiving prior DOAC therapy and those who were not, confirming our findings by a propensity-matched analysis of both groups. Results – Of the 2, 610 CES patients enrolled, the largest subgroup (43.4%) consisted of individuals with known AF who were not on anticoagulation therapy before the stroke event. A propensity-matched analysis adjusted for demographics, arrival time, AF type, HAS-BLED, and CHA ₂DS ₂-VA score (352 patients per group) revealed that patients taking DOACs presented with significantly milder strokes than non-users (mean admission NIHSS score: 8.84 ± 6.76 vs. 11.58 ± 6.98, p < 0.001). Stroke patients on DOAC therapy demonstrated significantly larger left atrial volume indices (LAVI) than non-users (56.05 ± 19.31 vs. 46.94 ± 14.33, respectively; p < 0.001). Conclusion – Non-adherence to DOACs is a substantial contributor to the CES burden. Prior DOAC use is associated with significantly reduced initial stroke severity. Patients with CES while on DOACs exhibited substantially larger left atria.