Determinants of direct oral anticoagulant selection after ischemic stroke or transient ischemic attack in patients with non-valvular atrial fibrillation: a 10-year retrospective analysis from a single center in Chile

Atrial fibrillation (AF) is a leading cause of cardioembolic ischemic stroke, accounting for approximately 20–30% of cases. Oral anticoagulation (OAC) is the cornerstone of secondary prevention, and direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists (VKAs). Although current guidelines consider age, body weight, renal function, and bleeding risk when selecting anticoagulation, they do not recommend a specific DOAC, leaving treatment choice largely to clinician judgment. Describing real-world prescribing patterns is therefore essential. This study aimed to assess temporal trends in OAC prescription at discharge among patients with ischemic stroke or transient ischemic attack (TIA) related to non-valvular AF in a Chilean advanced stroke center and to identify clinical variables associated with DOAC selection, particularly between apixaban and dabigatran, We conducted a single-center, retrospective, cross-sectional study including adults ≥ 18 years admitted with ischemic stroke or TIA attributed to AF and discharged on OAC between January 2013 and December 2023, using the institutional stroke registry (RECCA). Annual trends in OAC prescription were evaluated, and transitions in anticoagulant therapy among previously anticoagulated patients were visualized using a Sankey diagram. Clinical characteristics of apixaban and dabigatran users were compared using bivariable analyses. Statistical analyses were performed with Jamovi 2.6.44.0. Among 2,220 admissions for stroke or TIA, 323 patients (14.5%) had AF and were discharged on anticoagulation. After exclusions, 317 patients were analyzed. Median age was 81 years, and 55.2% were male. Hypertension (73%), diabetes (19.7%), and dyslipidemia (38.9%) were common, and 88.1% presented with ischemic stroke. At discharge, 270 patients (84.6%) received a DOAC and 47 (14.7%) a VKA. Apixaban was the most prescribed DOAC (54%), followed by dabigatran (37.8%) and rivaroxaban (8.1%). VKA use declined from 39.3% in 2013 to 3.6% in 2023, while apixaban increased from 3% to 64.2%. Apixaban users were older, had higher NIHSS scores, worse renal function, and greater baseline disability, whereas dabigatran was more frequently prescribed in younger and less severe cases. DOAC use increased markedly over the past decade, with apixaban emerging as the preferred agent, particularly in older, more comorbid, and renally impaired patients, while dabigatran remained more common in younger and lower-risk individuals. These findings reflect real-world practice and align with international evidence.