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September 11, 2026ACS Pharmacology & Translational ScienceOpen Access

Factor XI(a) Inhibition in Secondary Stroke Prevention: On the Cusp of a New Anticoagulation Paradigm

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Why the study?

Bleeding complications constrain conventional antithrombotic therapies for secondary stroke prevention, prompting evaluation of Factor XI as a hemostasis-sparing anticoagulation target.

Do Factor XI(a) inhibitors reduce recurrent ischemic stroke without increasing major bleeding in patients requiring secondary stroke prevention?

Design

Review

Key result

Asundexian 50 mg once daily added to antiplatelet therapy reduced recurrent ischemic stroke by 26% (HR 0.74; 95% CI 0.65-0.84) among patients with noncardioembolic stroke.

Authors

RARami A. Al‐Horani

Discussion

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Member takes

Overview

May support FXIa inhibitors for safer secondary stroke prevention; leaves open confirmation in additional randomized trials.

Structured PICO

Do Factor XI(a) inhibitors reduce recurrent ischemic stroke without increasing major bleeding in patients requiring secondary stroke prevention?

P
Population
Patients requiring secondary ischemic stroke prevention, including those with noncardioembolic stroke and atrial fibrillation.
I
Intervention
Factor XI(a) inhibitors (including oral small-molecule FXIa inhibitors like asundexian and milvexian, antisense oligonucleotides like fesomersen, and monoclonal antibodies like abelacimab and osocimab).
C
Comparator
Conventional antithrombotic therapies (e.g., antiplatelet therapy or apixaban, depending on the clinical context).
O
Outcome
Recurrent ischemic stroke and major bleeding.hard clinical

Main Result

Hazard Ratio: 0.74 (95% CI 0.65–0.84)

Factor XI(a) inhibitors, particularly asundexian, show promise for secondary prevention of noncardioembolic ischemic stroke by reducing recurrence without increasing major bleeding, though their efficacy is highly dependent on the clinical context.

Cite This Study

Rami A. Al‐Horani (2026) conducted a review in Ischemic stroke. Factor XI(a) inhibitors was evaluated on recurrent ischemic stroke (HR 0.74, 95% CI 0.65-0.84). Asundexian 50 mg once daily added to antiplatelet therapy reduced recurrent ischemic stroke by 26% (HR 0.74; 95% CI 0.65-0.84) among patients with noncardioembolic stroke.

synapsesocial.com/papers/6aa73dd9724d56ec8881285ahttps://doi.org/10.1021/acsptsci.6c00298
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