Key result
DOACs remain the mainstay for NVAF stroke prevention despite uncertainties regarding timing, breakthrough stroke, and ESUS.
Why the study?
Persistent uncertainties remain regarding direct oral anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation across several clinical scenarios.
What are the current uncertainties and optimal strategies for DOAC use in patients after stroke?
What are the current uncertainties and optimal strategies for DOAC use in patients after stroke?
This review highlights ongoing uncertainties in post-stroke anticoagulation, emphasizing the need for results from ongoing trials regarding DOAC timing, ESUS, and post-ICH management.
Purpose of review Direct oral anticoagulants (DOAC) are the mainstay of anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation. Persistent uncertainties remain in different areas, and this review discusses current dilemmas based on selected studies. Recent findings Optimal timing of DOAC initiation after a recent ischaemic stroke in patients with atrial fibrillation is currently unknown and subject of ongoing randomized controlled trials. Ischaemic stroke despite anticoagulant therapy in patients with atrial fibrillation is frequent, constitutes heterogeneous causes (competing stroke cause, medication error and cardioembolism despite anticoagulation) and optimal treatment is currently unknown. Thorough etiological work-up is justified. Recent randomized controlled trials found no beneficial effect of DOAC therapy in unselected patients with embolic stroke of undetermined source (ESUS). Currently ongoing trials targeting subgroup of ESUS patients with additional atrial cardiopathy will provide novel data. Cerebral mircobleeds combined in a novel risk score (MICON score) provide good predictive value to stratify the risk of intracranial haemorrhage in patients taking anticoagulants. Use of DOAC after intracerebral haemorrhage in patients with atrial fibrillation is subject of ongoing trials. Summary There are still significant uncertainties in anticoagulant management in patients with stroke. Ongoing trials will soon provide novel data to improve management of these patients.
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Siepen et al. (2021) conducted a review in Stroke and atrial fibrillation. Direct oral anticoagulants (DOAC) was evaluated. Direct oral anticoagulants are the mainstay for stroke prevention in nonvalvular atrial fibrillation, but significant uncertainties remain regarding optimal timing, breakthrough stroke, and use in ESUS.
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