{"id":"177e5b9f7045","type":"article","url":"https://hartvaat.nl/2026/09/01/doorbraakstroke-onder-doac-s-bij-atriumfibrilleren-vaak-door-niet-naleving-of-ni/","title":"Doorbraakstroke onder DOAC's bij atriumfibrilleren vaak door niet-naleving of niet-cardioembolische oorzaken","title_en":"Etiologic spectrum of direct oral anticoagulant breakthrough stroke in atrial fibrillation: The role of pseudo-failure and non-cardioembolic mechanisms.","category":"atriumfibrilleren","category_label":"Atriumfibrilleren","professions":["cardioloog","huisarts","internist"],"tags":[],"journal":"Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association","doi":"10.1016/j.jstrokecerebrovasdis.2026.108706","source_url":"https://doi.org/10.1016/j.jstrokecerebrovasdis.2026.108706","authors":["Lóránd Hegyi","Alex Beke","József Norbert Nemes","Nikoletta Szabó","Péter Klivényi","Tibor Gellért Hortobágyi","Ádám Annus"],"significance":5,"published":"2026-08-29","source_date":"2026-09-01","image":"","kennis":["https://hartvaat.nl/kennis/atriumfibrilleren/af-bij-ouderen/","https://hartvaat.nl/kennis/antistolling/doacs-overzicht/"],"congress":"","summary_en":"A retrospective cohort of 246 atrial fibrillation patients experiencing ischemic stroke while on DOAC therapy revealed that over 60% of events were classified as pseudo-failure, primarily driven by non-adherence or off-label underdosing. True DOAC failure accounted for 38% of cases and was strongly associated with competing non-cardioembolic mechanisms, particularly large-artery atherosclerosis (41.5%), whereas cardioembolism was less common (27.7%). True failure remained independently linked to non-cardioembolic stroke (adjusted OR 7.15; 95% CI 3.85–13.29; p < 0.001). These findings highlight that breakthrough strokes on DOACs often reflect medication issues or alternative vascular pathologies, underscoring the need for thorough etiologic reassessment and mechanism-specific secondary prevention before altering anticoagulant regimens.","created":"2026-08-23T00:46:00Z","updated":"2026-08-23T00:46:00Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Een retrospectieve analyse van 246 AF-patiënten met een ischemische stroke ondanks DOAC-gebruik toont aan dat ruim 60% van de gevallen valt onder 'pseudo-falen', voornamelijk door niet-naleving of off-label onderdosering. Bij het echte falen (38%) domineren niet-cardioembolische mechanismen, zoals grote-vaataterosclerose (41,5%), terwijl cardioembolie slechts in 27,7% voorkwam. Echte DOAC-falen was onafhankelijk geassocieerd met niet-cardioembolische oorzaken (OR 7,15; p < 0,001). Dit benadrukt dat bij stroke ondanks anticoagulatie eerst de etiologie en medicatietrouw systematisch moeten worden herbeoordeeld voordat de behandeling wordt aangepast.","abstract_original":"BACKGROUND: Ischemic stroke may occur despite direct oral anticoagulant (DOAC) therapy in patients with atrial fibrillation (AF), yet the underlying mechanisms remain incompletely understood. Although a growing number of studies have addressed DOAC breakthrough stroke, data from Central and Eastern Europe (CEE) are scarce, despite substantial regional differences in vascular risk factor burden and patient comorbidity. PATIENTS AND METHODS: We retrospectively analyzed consecutive AF patients presenting with acute ischemic stroke while receiving DOAC therapy at a tertiary comprehensive stroke center in Szeged, Hungary (2022-2024). Patients were classified as pseudo-failure or true-failure based on predefined criteria reflecting anticoagulation adequacy (including non-compliance, off-label underdosing, drug interactions, and valvular AF). Clinical characteristics and etiologic distributions were compared, and logistic regression assessed the association between failure type and non-cardioembolic stroke mechanisms. RESULTS: Among 246 patients, 61.8% were classified as pseudo-failure, most commonly due to non-compliance and off-label underdosing, while 38.2% were true-failure. In the true-failure group, non cardioembolic mechanisms predominated, with large-artery atherosclerosis accounting for 41.5% of cases, whereas cardioembolism was less frequent (27.7%). True-failure status was independently associated with non-cardioembolic stroke mechanisms after multivariable adjustment (adjusted OR 7.15, 95% CI 3.85-13.29; p < 0.001). CONCLUSIONS: In this CEE cohort, DOAC breakthrough strokes were frequently attributable to pseudo-failure, whereas true-failure cases showed a high prevalence of competing non-cardioembolic mechanisms. This excess of alternative etiologies may reflect the higher vascular risk burden and greater multimorbidity characteristic of CEE populations, underscoring the need for systematic etiologic reassessment and mechanism-specific secondary prevention."}