What are the recommended anticoagulants for stroke prevention?

Recommended Anticoagulants for Stroke Prevention

For patients at risk of stroke, direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are recommended over warfarin for stroke prevention in non-valvular atrial fibrillation due to their superior safety profile and similar or better efficacy. 1

Anticoagulant Selection Based on Stroke Etiology

Atrial Fibrillation

• Non-valvular AF:

  • First-line: DOACs (apixaban, dabigatran, rivaroxaban, edoxaban) 1
  • Second-line: Warfarin (target INR 2.0-3.0) if DOACs contraindicated 1
  • Apixaban may be preferred among DOACs due to lower bleeding risk 2

• Valvular AF (mechanical valves or moderate/severe mitral stenosis):

  • Warfarin (target INR 2.0-3.0) is recommended 1

Mechanical Heart Valves

• Aortic position: Warfarin (target INR 2.5, range 2.0-3.0) 3
• Mitral position: Warfarin (target INR 3.0, range 2.5-3.5) 3
• Caged ball/disk valves: Warfarin (target INR 3.0, range 2.5-3.5) plus aspirin 75-100 mg/day 3

Bioprosthetic Heart Valves

• First 3 months post-implantation: Warfarin (target INR 2.5, range 2.0-3.0) 3
• After 3 months: Long-term antiplatelet therapy 1

Left Ventricular Thrombus

• Warfarin (target INR 2.5, range 2.0-3.0) for at least 3 months 1

Evidence Supporting DOACs in Non-Valvular AF

Dabigatran (150 mg twice daily)

• Efficacy: Superior to warfarin (stroke/systemic embolism rate 1.11%/year vs 1.7%/year; RR 0.66) 1
• Safety:
  • Significantly lower intracranial hemorrhage (0.30%/year vs 0.74%/year; RR 0.40) 1
  • Similar overall major bleeding rates to warfarin 1
  • Increased gastrointestinal bleeding (1.51%/year vs 1.12%/year) 1

Apixaban (5 mg twice daily)

• Efficacy: Similar to other DOACs for stroke prevention 2
• Safety: Lowest bleeding risk among DOACs 2
  • 50% lower risk of major bleeding compared to dabigatran (HR 0.50) 2
  • 61% lower risk of major bleeding compared to rivaroxaban (HR 0.39) 2

Rivaroxaban (20 mg once daily)

• Efficacy: Non-inferior to warfarin for stroke prevention 4
• Safety: 30% increased risk of major bleeding compared to dabigatran (HR 1.30) 2

Special Considerations

Timing of Anticoagulation After Stroke

• Low hemorrhagic risk stroke: Consider starting anticoagulation 2-14 days after stroke 1
• High hemorrhagic risk stroke: Delay anticoagulation beyond 14 days 1
• TIA: Reasonable to initiate anticoagulation immediately 1

Renal Function

• End-stage renal disease/dialysis: Consider warfarin or dose-adjusted apixaban 1
• Moderate renal impairment: Dose adjustment may be needed for DOACs 5

Elderly Patients (≥75 years)

• DOACs maintain efficacy with potentially better safety profile than warfarin 6
• Apixaban and edoxaban may offer the best net clinical benefit in elderly patients 6

Common Pitfalls to Avoid

1. Inappropriate antiplatelet use: Patients suitable for anticoagulation should not receive antiplatelets alone for secondary stroke prevention in AF 1

2. Inadequate INR control: When using warfarin, maintaining time in therapeutic range >60% is critical for effective stroke prevention 1

3. Sudden discontinuation: DOACs have shorter half-lives than warfarin, making missed doses more risky for thrombotic complications 7

4. Failure to assess bleeding risk: Use validated tools (HAS-BLED, ATRIA) to assess bleeding risk before initiating anticoagulation 1

5. Overlooking drug interactions: DOACs have fewer interactions than warfarin but still require careful medication review 7

By following these evidence-based recommendations and considering patient-specific factors, clinicians can optimize stroke prevention strategies while minimizing bleeding risks.