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Lack of consensus on anticoagulation after acute ischemic stroke in atrial fibrillation

AAN 2019
Results of an internet-based questionnaire revealed a remarkable lack of consensus among US stroke neurologists on the timing of anticoagulation for secondary stroke prevention in patients with acute ischemic stroke due to non-valvular paroxysmal atrial fibrillation. Direct oral anticoagulants were the preferred anticoagulation strategy [1].

Risk of early recurrence of ischemic stroke due to atrial fibrillation may be high, but guidelines of the American Heart Association/American Stroke Association (AHA/ASA) provide imprecise recommendations on the timing and choice of anticoagulant for secondary prevention. A survey assessed current opinions of US board-certified stroke neurologists. In the survey, cases were presented of patients with acute ischemic stroke of varying severity and haemorrhagic transformation following paroxysmal atrial fibrillation. Of 1,239 stroke neurologists surveyed, 238 responded. These were some of the main outcomes:

  • For small acute ischemic stroke <1/3 middle cerebral artery (MCA) territory without haemorrhagic transformation, only 24% would start anticoagulation within 48 hours from stroke onset, although 80% would start anticoagulation by 7 days.
  • For greater stroke severity >1/2 MCA territory, 29% would start anticoagulation within 7 days, 48% in 7-14 days, and 23% would wait at least 14 days. Some would request stability imaging before starting anticoagulation.
  • Asymptomatic haemorrhagic transformation did not appreciably affect anticoagulation timing, but with symptomatic haemorrhagic transformation, 79% waited more than 14 days.
  • Most started anticoagulation earlier than initially intended in case of left atrium/left atrial appendage, acute left ventricular thrombi, or mechanical heart valve.
  • Direct anticoagulants were preferred by 62%. The most common reasons were low bleeding risk (82%), affordability/cost (55%), and availability of a specific reversal agent (42%). Acetylsalicylic acid was preferred by 57% in patients ineligible for direct anticoagulants.

1. Rybinnik I, et al. AAN 2019, S35.001.

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