Abstract 4360915: Association Between Direct Oral Anticoagulant Dose and Risk of Stroke/Systemic Embolism, Major Bleeding, or All-Cause Mortality in Patients with Ischemic Stroke and Atrial Fibrillation
Bibliographic record
Abstract
Background: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in patients with atrial fibrillation (AF); however, inappropriate dosages may increase risk for adverse events. Using data from the American Heart Association’s Get with the Guidelines-Stroke registry (GWTG-Stroke) linked with Medicare data, we evaluated the association of DOAC dosing with risk of stroke/systemic embolism, major bleeding, and all-cause mortality in older ischemic stroke patients with AF. Methods: We included ischemic stroke patients admitted to a GWTG-Stroke hospitals in Oct. 2012-Dec. 2019 who were > 66 years, had a history of AF/flutter, and were discharged on a DOAC (dabigatran, rivaroxaban, or apixaban). DOAC dosing was defined as appropriate (standard dose or appropriately adjusted dose), underdose (reduced dose without indications for dose reduction or dose lower than recommended), or overdose (standard dose in patients with indications for dose reduction or dose higher than recommended). Normalized inverse probability weighted generalized boosted models were used to estimate 1-year outcomes after discharge. Results: Of the 37,464 ischemic stroke survivors (median age: 81 years; 53% female; 7% non-Hispanic Black), 68% were discharged with the appropriate DOAC dose, 22% were underdosed and 10% were overdosed. Apixaban was the most common DOAC (68%), followed by rivaroxaban (23%) and dabigatran (9%). The cumulative 1-year incidence of stroke/systemic embolism were 7.1%, 7.0%, and 7.9% among patients who were appropriate dosed, underdosed, and overdosed. After multivariable adjustments, there was no significant association between DOAC dose and stroke/systemic embolism ( Table ). However, patients who were overdosed (aHR 1.11 [1.01-1.23]) were associated with greater risk of major bleeding compared with appropriately dosed patients. Furthermore, patients who were underdosed were associated with greater risk of all-cause mortality (aHR 1.12 [1.06-1.18]). No significant association with mortality risk was observed in those who were overdosed. Conclusion: In a nationwide registry of ischemic stroke survivors with AF, approximately one-third of patients were prescribed a non-recommended DOAC dose. Patients who were overdosed had greater risk of major bleeding, while those underdosed had a greater risk of all-cause mortality. Strategies, including medical education, to ensure appropriate DOAC dosing at discharge are needed to reduce risk of adverse outcomes.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".