Abstract Body: Background: The 2021 American Heart Association guidelines recommend antiplatelet or anticoagulation therapy for 3-6 months following acute cervical artery dissection (CeAD), driven by results from two randomized clinical trials which failed to demonstrate superiority of anticoagulation over antiplatelet therapy. This secondary analysis of STrOke Prevention in Cervical Artery Dissection (STOP-CAD) examined changes in oral antithrombotic strategies of CeAD following publication of these trials.
Methods: This is a pre-specified secondary analysis of a retrospective multinational observational cohort study evaluating outcomes related to antithrombotic treatment for acute CeAD (2015-2021). Adult patients with acute CeAD treated with oral antithrombotics (excluding vessel stenting) within 180 days of diagnosis were included. Anticoagulation (AC) was defined as direct oral anticoagulant therapy or vitamin K antagonist and antiplatelet (AP) was defined as single or dual oral antiplatelet therapy. The odds of oral anticoagulant use (over single or combination oral AP) therapy across each year were estimated using multivariable logistic regression and joinpoint regression.
Results: From 4,023 STOP-CAD patients, 3,345 had complete data regarding oral antithrombotic agent initiation and met inclusion criteria. Baseline characteristics per year did not differ significantly. Beginning in 2017, there was a decrease in the rate of oral AC (OAC) use with and without AP. Low NIHSS at baseline and single vertebral artery involvement were significantly associated with lower rates of oral AC use with or without AP use. Meanwhile; female sex, presence of an infarct on imaging, and presence of a partially occlusive thrombus were significantly associated with higher rates of OAC use. In joinpoint regression, the percentage of patients on OAC decreased and the percentage of patients on oral AP therapy increased over time. In 2015, 33.9% of patients received AC with or without AP, 18.7% received AC without AP and 81.3% received AP only. In contrast, in 2022 19.1% of patients received AC with or without AP 6.75% received AC without AP, and 93.4% received AP only.
Conclusions: Real-world clinical practices in the treatment of acute CeAD changed with a clearer understanding of the lack of definite benefit of OAC for all-comers with CeAD. While there may be certain subgroups for whom OAC is more effective than oral AP for CeAD, an increasing majority of patients receive AP over OAC.