Incidence of Ischemic Stroke among Patients Recently Initiated on Direct Oral Anticoagulants for Atrial Fibrillation

Abstract

Background: Ischemic strokes are a leading source of disability and death globally, particularly due to atrial fibrillation (AF), which is a significant risk factor. While prescribing anticoagulation DOACs to patients with AF for cardioembolism stroke prevention, real-world scenarios show persistent stroke events, which connote suboptimal functioning of the controlled interventions. To establish the rate of ischemic stroke among patients with newly prescribed DOACs for atrial fibrillation (AF)and to evaluate the relevant demographic, clinical, and laboratory features. Methods: A descriptive cross-sectional study was conducted in the Emergency Department of Lady Reading Hospital, Peshawar from May 2024 to May 2025.  A total of 184 patients aged 30–60 years, presenting with acute ischemic stroke and recently started on DOACs, were enrolled using consecutive non-probability sampling. Data were collected through structured clinical evaluation, ECG confirmation of AF, neuroimaging, and relevant laboratory tests. Statistical analysis was performed using SPSS version 21.0, with p-values ≤ 0.05 considered significant. Results: The mean age of patients was 51.3 ± 7.6 years, with females comprising 51.6% of the sample. Ischemic stroke occurred in 20.1% of patients despite recent initiation of DOACs. Atrial fibrillation was present in 60.3% of cases, but no significant association with stroke outcome was observed. In contrast, male gender showed a statistically significant link with stroke occurrence (p = 0.0191). Most patients had normal liver and renal function, though abnormalities in serum electrolytes and glucose levels were common. Conclusion: A notable proportion of patients developed ischemic stroke despite DOAC use, suggesting that anticoagulation alone may not be sufficient in high-risk cases. Male gender appeared to be a significant risk factor, whereas family history and documented AF were not. These findings highlight the need for comprehensive stroke prevention strategies beyond anticoagulation, including close monitoring and metabolic risk control.