Residual Risk of Recurrent Stroke Despite Anticoagulation in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

IF 20.4 1区医学 Q1 CLINICAL NEUROLOGY

JAMA neurology Pub Date : 2025-05-21 DOI:10.1001/jamaneurol.2025.1337

John J McCabe,Yuen Cheung,Marianne Foley,Stephen O Brennan,Jane Buckley,Pol Camps Renom,Tim Cassidy,Ronan Collins,Eamon Dolan,Gerrit M Grosse,Joseph Harbison,Kirstyn James,Kayvan Khadjooi,Isuru Induruwa,Mira Katan,Senan Maher,Margaret O'Connor,Martin O'Donnell,Francisco Purroy,Padraig Synott,Peter J Kelly

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引用次数: 0

Abstract

Importance Atrial fibrillation (AF) is a leading cause of stroke, and oral anticoagulants (OAC) reduce this risk. However, there are limited data on the residual risk of recurrent stroke in patients with AF. Objective To determine the recurrent stroke risk in patients with AF by performing a systematic review and meta-analysis. Data Sources Eligible studies were identified by searching Ovid MEDLINE and Embase from inception (Ovid: January 1946; Embase: January 1970) until January 2025. Study Selection Eligible studies enrolled patients with prior ischemic stroke and AF, reported information on incidence of recurrent stroke, and had follow-up data for 1 or more years. Three reviewers independently screened abstracts and performed full-text reviews. Data Extraction and Synthesis Data extraction was performed by 2 reviewers and independently verified by a third. Incidence rates were pooled using random-effects meta-analysis. Analysis was repeated in patients whose qualifying event occurred despite OAC. Study quality was assessed using the Quality In Prognosis Studies tool. Main Outcomes and Measures The primary outcome was recurrent ischemic stroke. The secondary outcomes were any recurrent stroke (ischemic stroke or intra-cerebral hemorrhage [ICH]) and ICH during follow-up. Results A total of 23 studies were identified, which included 78 733 patients and 140 307 years of follow-up. The median proportion of OAC use across studies was 92%. The pooled incidence of recurrent ischemic stroke was 3.75% per year (95% CI, 3.17%-4.33%). The risk was higher in noninterventional observational cohorts (4.20% per year; 95% CI, 3.41%-4.99%) compared with randomized clinical trials (2.26% per year; 95% CI, 1.96%-2.57%) (P value for interaction <.001). The risk of any recurrent stroke was 4.88% per year (95% CI, 3.87%-5.90%), and the risk of ICH was 0.58% per year (95% CI, 0.43%-0.73%). In patients with stroke despite OAC, the risk was 7.20% per year (95% CI, 5.05%-9.34%) for ischemic stroke, 8.96% per year (95% CI, 8.25%-9.67%) for any stroke, and 1.40% per year (95% CI, 0.40%-2.40%) for ICH. Conclusions and Relevance In this systematic review and meta-analysis, even with modern prevention therapy, the residual recurrence risk after AF-related stroke is high, with an estimated 1 in 6 patients experiencing a recurrent ischemic stroke at 5 years. These data demonstrate an urgent need to improve our understanding of the biological processes responsible for recurrence, improve risk stratification, and develop new secondary prevention strategies after AF-related stroke.

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房颤患者抗凝后卒中复发的剩余风险：一项系统回顾和荟萃分析。

房颤（AF）是中风的主要原因，口服抗凝剂（OAC）可降低这一风险。然而，房颤患者卒中再发的剩余风险数据有限。目的通过系统评价和荟萃分析确定房颤患者卒中再发风险。数据来源通过搜索Ovid MEDLINE和Embase从开始(Ovid: January 1946；大使馆：1970年1月)至2025年1月。研究选择符合条件的研究纳入了有缺血性卒中和房颤病史的患者，报告了卒中复发的发生率，并有1年或更长时间的随访数据。三位审稿人独立筛选摘要并进行全文评审。数据提取和综合数据提取由2位审稿人完成，并由第三位审稿人独立验证。使用随机效应荟萃分析汇总发病率。在OAC发生合格事件的患者中重复分析。使用预后质量研究工具评估研究质量。主要结局和测量：主要结局为复发性缺血性卒中。次要结局是任何复发性脑卒中（缺血性脑卒中或脑出血[ICH]）和随访期间的脑出血。结果共纳入23项研究，包括78 733例患者和140 307年的随访。所有研究中OAC使用的中位数比例为92%。缺血性卒中复发的总发生率为每年3.75% （95% CI, 3.17%-4.33%）。非干预性观察组的风险更高(每年4.20%；95% CI, 3.41%-4.99%)与随机临床试验(2.26% /年；95% CI, 1.96% ~ 2.57%)（相互作用的P值< 0.001）。卒中复发的风险为每年4.88% (95% CI, 3.87%-5.90%)，脑出血的风险为每年0.58% （95% CI, 0.43%-0.73%）。在有OAC的卒中患者中，缺血性卒中的风险为7.20% /年（95% CI, 5.05%-9.34%），任何卒中的风险为8.96% /年（95% CI, 8.25%-9.67%）， ICH的风险为1.40% /年（95% CI, 0.40%-2.40%）。结论和相关性在本系统综述和荟萃分析中，即使采用现代预防治疗，房颤相关卒中后残留复发风险仍然很高，估计每6例患者中就有1例在5年内再次发生缺血性卒中。这些数据表明，迫切需要提高我们对复发的生物学过程的理解，改善风险分层，并在房颤相关卒中后制定新的二级预防策略。

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来源期刊

JAMA neurology CLINICAL NEUROLOGY-

CiteScore

41.90

自引率

1.70%

发文量

250

期刊介绍： JAMA Neurology is an international peer-reviewed journal for physicians caring for people with neurologic disorders and those interested in the structure and function of the normal and diseased nervous system. The Archives of Neurology & Psychiatry began publication in 1919 and, in 1959, became 2 separate journals: Archives of Neurology and Archives of General Psychiatry. In 2013, their names changed to JAMA Neurology and JAMA Psychiatry, respectively. JAMA Neurology is a member of the JAMA Network, a consortium of peer-reviewed, general medical and specialty publications.