ABSTRACT NUMBER: ESOC2026A35 IMPACT OF CANCER ON OUTCOMES FOLLOWING BREAKTHROUGH ISCHEMIC STROKE ON ORAL ANTICOAGULANTS FOR ATRIAL FIBRILLATION: INSIGHTS FROM THE ASPERA-R STUDY

Abstract Background and aims Breakthrough ischemic stroke during oral anticoagulation (OAC) for atrial fibrillation (AF) represents a major therapeutic challenge, especially in patients with cancer, who face competing risks of thrombosis and bleeding. This study investigated the impact of cancer on 90-day outcomes after ischemic stroke on OAC. Methods We analyzed patients with AF who experienced ischemic stroke while on continuous OAC enrolled in the international retrospective ASPERA-R study, comprising 35 stroke centers across 9 countries. Inverse probability weighting (IPW) was applied to adjust for baseline imbalances, and weighted Cox, ordinal logistic and generalized liner models were used to estimate adjusted 90-day risks for the primary (ischemic stroke or TIA), secondary (mRS shift, vascular/all-cause death), and safety (moderate-to-severe bleeding, intracranial hemorrhage, 24-h hemorrhagic transformation) outcomes. Results Among 1,649 included patients (mean age 78.0 ± 10.7 years; 45.8% male), 247 (15.0%) had cancer, of whom 87 (35.2%) active and 160 (64.8%) in remission. After IPW, patients with cancer had a higher 90-day risk of new ischemic stroke or TIA (8.2% vs 2.8%; aHR 2.56,95% CI 1.59–4.13;P < 0.001) and worse mRS score (aOR 1.29,95% CI 1.08-1.54;P = 0.005) than those without cancer. Active cancer conferred a > 4-fold higher risk of new ischemic stroke/TIA and nearly 3-fold of moderate-to-severe bleeding. Hematological malignancies carried higher risk for both new ischemic stroke/TIA and moderate-to-severe bleeding versus solid malignancies. Conclusion Cancer, particularly active and hematological malignancies, substantially worsens 90-day prognosis after breakthrough stroke on OAC for AF. Conflict of interest Prof Casolla declares speaker’s fees from ACTICOR Biotech and SANOFI-AVENTIS France. Prof Sacco reports compensation from Novartis for other services; compensation from Novo Nordisk for consultant services; compensation from Boehringer Ingelheim for consultant services; compensation from Teva Pharmaceutical Industries for consultant services; compensation from Allergan for consultant services; employment by Università degli Studi dell’Aquila; compensation from Novartis for consultant services; compensation from Allergan for consultant services; compensation from PFIZER CANADA INC for consultant services; compensation from Abbott Canada for consultant services; compensation from H. Lundbeck A S for consultant services; compensation from AstraZeneca for consultant services; and. Figure 1 - belongs to Results