BACKGROUND: Breakthrough ischaemic stroke during oral anticoagulation (OAC) for atrial fibrillation (AF) represents a major therapeutic challenge, especially in patients with cancer, who face competing risks of thrombosis and bleeding. This study investigated the impact of cancer on 90-day outcomes after ischaemic stroke on OAC. PATIENTS AND METHODS: We analysed patients with AF who experienced ischaemic stroke while on continuous OAC enrolled in the international retrospective ASPERA-R study, comprising 35 stroke centres across 9 countries. Inverse probability weighting was applied to adjust for baseline imbalances, and weighted Cox, ordinal logistic and generalised linear models were used to estimate adjusted 90-day risks for the primary (ischaemic stroke or TIA), secondary (mRS shift, vascular/all-cause death) and safety (moderate-to-severe bleeding, ICH, 24-h haemorrhagic transformation) outcomes. RESULTS: Among 1649 included patients (mean age 78.0 ± 10.7 years; 45.8% male), 247 (15.0%) had cancer, of whom 87 (35.2%) had active cancer and 160 (64.8%) were in remission. After weighting, patients with cancer had a significantly higher 90-day risk of new ischaemic stroke or TIA (8.2% vs 2.8%; adjusted hazard ratio [aHR] 2.56; 95% CI, 1.59-4.13; P < .001) and worse 90-day mRS score distribution (adjusted odds ratio 1.29; 95% CI, 1.08-1.54; P = .005) than those without cancer. Active cancer conferred a > 4-fold higher risk of new ischaemic stroke or TIA (HR 4.48, 95% CI, 2.46-8.13; P < .001) and nearly 3-fold higher risk of moderate-to-severe bleeding (HR 2.77; 95% CI, 1.30-5.88; P = .008). Patients with cancer in remission showed increased ischaemic risk (HR 2.60; 95% CI, 1.59-5.25; P = .001) but not bleeding risk. Haematological malignancies carried a higher risk for both new ischaemic stroke or TIA (HR 3.06; 95% CI, 1.69-5.54; P = .001) and moderate-to-severe bleeding (HR 3.47, 95% CI, 1.57-7.70; P = .006) compared to solid malignancies. CONCLUSION: Cancer, particularly active and haematological malignancies, substantially worsens 90-day prognosis after breakthrough stroke on OAC, underscoring the need for refined risk stratification and tailored secondary prevention. TRIAL REGISTRATION: URL: www.clinicaltrials.gov; Unique identifier: NCT06823466.
Impact of cancer on outcomes following breakthrough ischaemic stroke on oral anticoagulants for atrial fibrillation: insights from the ASPERA-R study / Foschi, Matteo; De Santis, Federico; Gabriele, Francesca; D'Anna, Lucio; Zini, Andrea; Paolucci, Matteo; Forlivesi, Stefano; Migliaccio, Ludovica; Viola, Maria Maddalena; Rizzo, Angelo Cascio; Sessa, Maria; Schwarz, Ghil; Tortorella, Rachele; Banerjee, Soma; Desai, Gaurav; Jaffar, Muhammad; Prandin, Gabriele; Pantoni, Leonardo; Mele, Francesco; Scopelliti, Giuseppe; Cova, Ilaria; Valente, Mariarosaria; Maisano, Domenico; Antonelli, Luca; Bagnato, Maria Rosaria; Di Mauro, Giovanni; Bernocchi, Francesca; Di Donna, Martina Gaia; Casolla, Barbara; Mazloum, Myriam Perla; Kacani, Kristina; Djeghlal, Noufel-Anis; González-Martín, Laura; Rigual, Ricardo; Fuentes, Blanca; Hervás, Carlos; Candelaresi, Paolo; Andreone, Vincenzo; De Mase, Antonio; Spina, Emanuele; De Sousa, Diana Aguiar; Souza, Mariana Almudi; Fior, Alberto; Serôdio, Miguel; Caliandro, Pietro; Zauli, Aurelia; Reale, Giuseppe; Abdelalim, Ahmed; Ahmed, Sandra; Soliman, Nourhan Mohamed; Zhang, Liqun; Latimer, Tara; Elboghday, Muhammad; Elbassiouny, Ahmed Aly; Roushdy, Tamer; Shokri, Hossam; Ferrari, Federica; Loizzo, Nicola Davide; Mazzacane, Federico; Guarino, Maria; Barone, Valentina; Forti, Paola; Rinaldi, Giuseppe; Rossi, Marco Vito; Laterza, Vincenzo; Frisullo, Giovanni; Rizzo, Pier Andrea; Broccolini, Aldobrando; Mannino, Marina; Terruso, Valeria; Caggiula, Marcella; Rizzo, Annalisa; Fonseca, Ana Catarina; Antunes, Bernardo; Barbosa, Ana M; Budincevic, Hrvoje; Crnac, Petra; Viticchi, Giovanna; Silvestrini, Mauro; Barba, Lorenzo; Otto, Markus; Lochner, Piergiorgio; Landau, Benjamin; Buddha, Sandeep; Khalil, Roumeisa; Piscaglia, Maria Grazia; Minguzzi, Elena; Zedde, Marialuisa; Nasreldein, Ahmed; Vinciguerra, Luisa; Costa, Luis; Elsayed, Ahmed Elsaid; Albanna, Mona; Tudisco, Laura; Mosconi, Maria Giulia; Merlino, Giovanni; Polymeris, Alexandros; Ornello, Raffaele; Sacco, Simona. - In: EUROPEAN STROKE JOURNAL. - ISSN 2396-9881. - ELETTRONICO. - 11:2(2026), pp. aakag015."-"-aakag015."-". [10.1093/esj/aakag015]
Impact of cancer on outcomes following breakthrough ischaemic stroke on oral anticoagulants for atrial fibrillation: insights from the ASPERA-R study
Prandin, Gabriele;
2026-01-01
Abstract
BACKGROUND: Breakthrough ischaemic stroke during oral anticoagulation (OAC) for atrial fibrillation (AF) represents a major therapeutic challenge, especially in patients with cancer, who face competing risks of thrombosis and bleeding. This study investigated the impact of cancer on 90-day outcomes after ischaemic stroke on OAC. PATIENTS AND METHODS: We analysed patients with AF who experienced ischaemic stroke while on continuous OAC enrolled in the international retrospective ASPERA-R study, comprising 35 stroke centres across 9 countries. Inverse probability weighting was applied to adjust for baseline imbalances, and weighted Cox, ordinal logistic and generalised linear models were used to estimate adjusted 90-day risks for the primary (ischaemic stroke or TIA), secondary (mRS shift, vascular/all-cause death) and safety (moderate-to-severe bleeding, ICH, 24-h haemorrhagic transformation) outcomes. RESULTS: Among 1649 included patients (mean age 78.0 ± 10.7 years; 45.8% male), 247 (15.0%) had cancer, of whom 87 (35.2%) had active cancer and 160 (64.8%) were in remission. After weighting, patients with cancer had a significantly higher 90-day risk of new ischaemic stroke or TIA (8.2% vs 2.8%; adjusted hazard ratio [aHR] 2.56; 95% CI, 1.59-4.13; P < .001) and worse 90-day mRS score distribution (adjusted odds ratio 1.29; 95% CI, 1.08-1.54; P = .005) than those without cancer. Active cancer conferred a > 4-fold higher risk of new ischaemic stroke or TIA (HR 4.48, 95% CI, 2.46-8.13; P < .001) and nearly 3-fold higher risk of moderate-to-severe bleeding (HR 2.77; 95% CI, 1.30-5.88; P = .008). Patients with cancer in remission showed increased ischaemic risk (HR 2.60; 95% CI, 1.59-5.25; P = .001) but not bleeding risk. Haematological malignancies carried a higher risk for both new ischaemic stroke or TIA (HR 3.06; 95% CI, 1.69-5.54; P = .001) and moderate-to-severe bleeding (HR 3.47, 95% CI, 1.57-7.70; P = .006) compared to solid malignancies. CONCLUSION: Cancer, particularly active and haematological malignancies, substantially worsens 90-day prognosis after breakthrough stroke on OAC, underscoring the need for refined risk stratification and tailored secondary prevention. TRIAL REGISTRATION: URL: www.clinicaltrials.gov; Unique identifier: NCT06823466.| File | Dimensione | Formato | |
|---|---|---|---|
|
aakag015.pdf
accesso aperto
Tipologia:
Documento in Versione Editoriale
Licenza:
Creative commons
Dimensione
3.32 MB
Formato
Adobe PDF
|
3.32 MB | Adobe PDF | Visualizza/Apri |
Pubblicazioni consigliate
I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
