Between the Devil and Deep Blue Sea - Anticoagulation in Cardioemboilc Stroke

Stroke is the commonest cause of mortality and morbidity after coronary artery disease. According in India stroke factsheet updated in 2021, the estimated age-adjusted prevalence rate for stroke ranges between 84-262/100,000 in rural and 334-424/100,000 in urban areas. Ischemic stroke is the commonest followed by cardioembolic which is 20% which may be higher in developing countries because of illiteracy and lower socioeconomic status. Cardioembolic strokes are usually severe in presentation and prone for early recurrence. The risk of long term recurrence and mortality are also high. Hemorrhagic transformation occurs in up to 71% of cardioembolic strokes. Atrium, ventricle and valves are the high-risk origins. This article highlights the importance of balancing between thromboembolism and bleeding risks while making therapeutic decisions. Anticoagulation is indicated both for primary and secondary stroke prevention. The role of Novel oral anticoagulant versus warfarin and they edge over as they don't need INR monitoring .Thrombogenic atrial substrate even in the absence of atrial brillation can predispose to atrial thromboembolism.TEE allows better visualization (aortic atheromas, patent foramen ovale, atrial septal aneurysms) of earlier crytogenic lesions elucidating a cause and thereby reducing the embolic risk. Because of varied etiology and presentation, a tailored individual approach is needed