What to do with anti-platelets (antiplatelet agents) in a patient with atrial fibrillation who has had a stroke and is starting to walk?

Management of Antiplatelet Therapy in Stroke Patients with Atrial Fibrillation

For patients with atrial fibrillation who have had a stroke and are beginning to ambulate, antiplatelet therapy should be discontinued and oral anticoagulation alone should be used for secondary stroke prevention. 1

Risk Assessment and Anticoagulation Recommendations

• Patients with atrial fibrillation who have already experienced a stroke have a CHA₂DS₂-VASc score of at least 2 (due to prior stroke/TIA counting as 2 points), placing them at high risk for recurrent stroke 2
• For these high-risk patients, oral anticoagulation is strongly recommended over no therapy, aspirin, or combination therapy with aspirin and clopidogrel 2
• Direct oral anticoagulants (DOACs) are preferred over warfarin for non-valvular atrial fibrillation due to their lower risk of intracranial hemorrhage 1

Discontinuation of Antiplatelet Therapy

• Continuing antiplatelet therapy along with oral anticoagulation significantly increases bleeding risk without providing additional stroke prevention benefit 2
• Low-dose aspirin is generally recommended only during hospitalization and should be discontinued prior to or upon discharge in most patients 2
• The American College of Cardiology strongly recommends against antiplatelet therapy alone (monotherapy or aspirin in combination with clopidogrel) for stroke prevention in AF, regardless of stroke risk 1

Choice of Anticoagulant

• For patients with non-valvular atrial fibrillation, DOACs (apixaban, dabigatran, rivaroxaban, edoxaban) are preferred over warfarin 1
• Specific DOAC recommendations:
  • Dabigatran 150 mg twice daily is suggested over adjusted-dose vitamin K antagonist therapy 2
  • Apixaban has shown a 7% absolute risk reduction in stroke or systemic embolism over 3.5 years compared to aspirin in patients with a history of stroke 3
  • DOACs require dose adjustment based on renal function 1

Important Considerations and Precautions

• Bleeding risk assessment should be performed, focusing on modifiable risk factors such as uncontrolled blood pressure, alcohol excess, and concomitant use of NSAIDs 1
• Patients should be warned that DOACs can cause bleeding which can be serious and rarely may lead to death 4, 5
• Signs of bleeding to monitor include unexpected bleeding, red/pink/brown urine, red or black stools, coughing up blood, vomiting blood, unexpected pain/swelling, headaches, or dizziness 4, 5
• Never discontinue anticoagulation after stroke in patients with atrial fibrillation without consulting the prescribing physician, as stopping increases the risk of recurrent stroke 4, 5

Common Pitfalls to Avoid

• Using antiplatelet therapy alone or in combination with anticoagulation when oral anticoagulation alone is indicated 1
• Overestimating bleeding risk leading to inappropriate withholding of anticoagulation 1
• Discontinuing anticoagulation when a patient begins to ambulate - mobility status does not change the need for anticoagulation in AF patients with prior stroke 1
• Inadequate INR control (target 2.0-3.0) when using warfarin, which reduces both safety and effectiveness 1