What is the best treatment for stroke prevention in an 89-year-old patient with reduced left ventricular ejection fraction (LVEF) of 25% and a history of transient ischemic attack (TIA)?

From the Guidelines

For an 89-year-old patient with reduced ejection fraction (EF) of 25% and a history of transient ischemic attack (TIA), the best treatment for stroke prevention is oral anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban (Eliquis) 5 mg twice daily or warfarin with a target INR of 2.0-3.0. This recommendation is based on the significantly increased risk of cardioembolic stroke in patients with severely reduced EF, as the poor cardiac contractility promotes blood stasis and thrombus formation in the left ventricle 1. According to the guidelines, anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor, such as age 75 y or greater, hypertension, HF, impaired LV systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus 1. Additionally, the patient should receive guideline-directed medical therapy for heart failure including beta-blockers, ACE inhibitors or ARBs, and aldosterone antagonists as tolerated to improve cardiac function. Some key points to consider in the management of this patient include:

• The use of antiplatelet therapy alone (such as aspirin or clopidogrel) is insufficient for stroke prevention in this high-risk scenario with severely reduced EF and prior TIA 1.
• Regular monitoring of renal function, complete blood count, and, if using warfarin, INR is essential 1.
• The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient 1. It is also important to note that the patient's age, weight, and serum creatinine levels should be taken into account when selecting the dose of apixaban, with a dose reduction to 2.5 mg twice daily if the patient has at least two of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation ARISTOTLE

... The primary objective of ARISTOTLE was to determine whether apixaban 5 mg twice daily (or 2. 5 mg twice daily) was effective (noninferior to warfarin) in reducing the risk of stroke (ischemic or hemorrhagic) and systemic embolism. ... Apixaban was superior to warfarin for the primary endpoint of reducing the risk of stroke and systemic embolism (Table 9 and Figure 4). ... Table 9: Key Efficacy Outcomes in Patients with Nonvalvular Atrial Fibrillation in ARISTOTLE (Intent-to-Treat Analysis) Apixaban N=9120 n (%/year) Warfarin N=9081 n (%/year) Hazard Ratio (95% CI)P-value Stroke or systemic embolism 212 (1.27) 265 (1.60) 0.79 (0.66,0.95) 0.01

The best treatment for stroke prevention in an 89-year-old patient with reduced ejection fraction (25%) and a history of TIA is apixaban.

• The patient's age and history of TIA qualify as risk factors for stroke.
• Apixaban has been shown to be superior to warfarin in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, as demonstrated in the ARISTOTLE study 2.
• The recommended dose for patients with at least 2 of the following characteristics: age greater than or equal to 80 years, body weight less than or equal to 60 kg, or serum creatinine greater than or equal to 1.5 mg/dL is 2.5 mg twice daily.

From the Research

Treatment Options for Stroke Prevention

The patient in question is an 89-year-old with a reduced ejection fraction of 25% and a history of transient ischemic attack (TIA). The best treatment for stroke prevention in this case would involve anticoagulation therapy.

• The use of oral anticoagulants such as apixaban, rivaroxaban, and edoxaban has been recommended for patients with atrial fibrillation (AF) and heart failure (HF) 3.
• A study published in The Lancet. Neurology found that apixaban reduced the risk of stroke or systemic embolism compared to aspirin in people with subclinical atrial fibrillation and a history of stroke or TIA 4.
• The study also found that apixaban led to a 7% absolute risk reduction in stroke or systemic embolism over 3.5 years in people with subclinical atrial fibrillation and a history of stroke or TIA, compared to a 1% absolute risk reduction for individuals without a previous history of stroke or TIA 4.
• Another study published in Stroke found that early initiation of anticoagulation with apixaban after TIA or acute ischemic stroke (AIS) from AF did not appear to compromise patient safety 5.

Considerations for Treatment

When considering treatment options for this patient, several factors should be taken into account, including:

• The patient's reduced ejection fraction and history of TIA, which increase the risk of stroke and systemic embolism 3, 4.
• The potential benefits and risks of anticoagulation therapy, including the risk of major bleeding 4, 5.
• The patient's age and any comorbidities, which may affect the choice of treatment 6, 7.

Medication Options

The following medications may be considered for stroke prevention in this patient:

• Apixaban, which has been shown to reduce the risk of stroke or systemic embolism in people with subclinical atrial fibrillation and a history of stroke or TIA 4.
• Other oral anticoagulants, such as rivaroxaban and edoxaban, which have been recommended for patients with AF and HF 3.
• Beta-blockers, which may be used to control heart rate and reduce the risk of stroke in patients with AF and HF 6.