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Since the introduction of novel oral anticoagulants (NOACs) in 2010, their use in patients with cardioembolic strokes has steadily increased. Meta-analyses show that NOACs have an overall reduction in stroke, systemic embolism, and mortality compared to vitamin K antagonists. However, patients on NOACs cannot receive IV thrombolytics when they have a breakthrough stroke. The purpose of this study is to investigate if patients with atrial fibrillation (AF) on NOACs have a lower morbidity and mortality from their ischemic strokes compared to AF patients who received IV thrombolytics. 

A single-center descriptive study was conducted among ischemic stroke patients with AF who presented within 4.5 hours of last known well from 2015 to 2019. Of the 696 patients admitted, those with atrial fibrillation or atrial flutter found on admission or workup were included (n=154). Of the AF patient group, 75 patients received IV thrombolytics and 23 patients did not because of NOAC use. Student t-test and chi-square test were used to compare the two groups.

There was no difference between age, sex, history of hypertension, hyperlipidemia, diabetes, coronary artery disease, previous stroke, and smoking between the IV thrombolytics group and NOACs group. NIH Stroke Scale (NIHSS) on admission was significantly higher for patients who received IV thrombolytics (median=12) compared to patients on NOACs (median=5, p=0.02). However, NIHSS at discharge was not significantly different (IV thrombolytics median=4, NOACs median=2, p=0.74). Death at 90 days or discharged on comfort care was not significantly different between both groups (IV thrombolytics 17%, NOACs 22%, p=0.53).

In this single-center study, there was no difference in morbidity and mortality outcomes for AF patients on NOACs compared to patients who received IV thrombolytics. However, the lower NIHSS in the NOACs group on admission is suggestive that NOACs can lessen the severity of breakthrough strokes for AF patients.