Abstract TP145: Direct Oral Anticoagulants versus Aspirin for Prevention of Covert Cerebral Infarction: A Meta-Analysis

Background: Studies evaluating direct oral anticoagulant (DOAC) therapy in reducing covert brain infarction (CBI), compared to aspirin monotherapy, have generally been small and yielded inconclusive results. We, therefore, performed a systematic review and meta-analysis to summarize the effect of DOAC use with incident CBI and ischemic stroke. Methods: Using PRISMA guidelines, we systematically searched PubMed, Scopus, Embase, and the Cochrane Library from inception to August 1, 2025, for randomized controlled trials (RCTs) or RCT substudies comparing DOACs with aspirin. Studies were included if magnetic resonance imaging (MRI) scans of the brain were performed during follow-up, and rates of CBI were reported. The co-primary outcomes were incident CBI on follow-up brain MRI, and any stroke defined as a composite of CBI or symptomatic ischemic stroke. After assessing study heterogeneity, we performed a meta-analysis using DerSimonian-Laird random-effects models to generate log odds ratios (OR) and evaluate the strength of association between the type of antithrombotic therapy and outcomes. A subgroup analysis was performed stratified by the type of indication for antithrombotic therapy (primary vs. secondary prevention). Results: Six studies, with a total of 3,438 patients, were eligible for inclusion in the meta-analysis. DOAC use was associated with lower odds of any stroke (log OR, -0.47; 95% confidence interval, [CI], -0.76 to -0.19; I 2 = 0.0%, Figure 1), but not with CBI (log OR, -0.21; 95% CI, -0.49 to 0.07; I 2 = 0.0%, Figure 2). Conclusions: In this meta-analysis of patients at risk for ischemic cerebrovascular disease, DOAC use versus antiplatelet therapy was associated with lower odds of the composite outcome of CBI or symptomatic ischemic stroke, but not with reduced risk of CBI alone.