Abstract WP151: Antithrombotic therapy for Secondary Stroke prevention in patients with Symptomatic Large Artery Atherosclerosis and Atrial fibrillation: A multi-center experience (FIB-CAS retrospect)

Background and aims: The coexistence of atrial fibrillation (AF) and symptomatic large artery atherosclerosis (LAA) poses a high risk of recurrence in stroke patients, yet available evidence for the optimal antithrombotic strategies remains limited. This study reports a multicenter experience evaluating prescribed antithrombotic regimens and their association with stroke recurrence and hemorrhagic events Methods: We retrospectively analyzed patients with stroke due to symptomatic intracranial (sICAS) or extracranial (sECAS) atherosclerosis (50-99% stenosis) who had concomitant AF across 4 academic stroke centers. Patients were grouped by discharge antithrombitics: single anticoagulant (sAC), anticoagulant+antiplatelet (sAC+sAP), antiplatelet (sAP), dual antiplatelet (DAPT), or triple therapy (sAC+DAPT). Primary outcomes were recurrent stroke, symptomatic hemorrhagic events and mortality occurred during 1-year follow-up Results: Of 191 patients (40% female, 20% Black, median age 75 (IQR 68-83), 101(53%) patients had sICAS, 36 (19%) sECAS, and 54 (28%) tandem disease. Twenty-seven (14%) patients received extracranial carotid stent and 20 (10%) underwent carotid endarterectomy. Discharge regimens were sAC 25%, sAC+sAP 33%, sAP 19%, DAPT 19%, sAC+DAPT 4%. Outcomes at 1-year were available for 174 patients. Stroke recurred in 21(11%) patients including 12 (57%) within 90-days. Recurrent stroke was higher for sAC compared to sAC+sAP (17% vs. 3%;p=0.02) at 90 days; however at 1-year rates were similar 0% sAC vs. 5% sAC+sAP (p=0.24). Symptomatic hemorrhagic events occurred in 14%, with no significant difference between sAC and sAC+sAP at 90 days (4% vs.10%,p=0.46) or 1-year (3% vs.10%,p=0.27). Mortality was substantial: 10 in-hospital deaths and 55 post-discharge: 25% within 90 days, 40% between 90 days and 1-year. In the sICAS subgroup recurrent stroke in 90 days was higher for sAC compared to sAC+sAP (21% vs. 3%;p=0.04). No difference in symptomatic hemorrhagic events at 90-days (4% sAC vs. 6% sAC+sAP). At one year symptomatic hemorrhagic events were more frequent in sAC+sAP (4% vs.13%) but the difference was not significant (p=0.26) Conclusion: AF patients with stroke due to sICAS or sECAS had high early recurrence and mortality. AC+sAP may reduce the risk of recurrent stroke but was associated with a non-significant increase in hemorrhage. Prospective studies needed to identify the optimal antithrombotic treatment strategy for patients with symptomatic LAA and AF