What is the recommended treatment for a patient with acute ischemic stroke, history of Hypertrophic Obstructive Cardiomyopathy (HOCM), and Atrial Fibrillation (AF) who is already on apixaban (eliquis) 5mg twice a day?

Treatment Guidelines for Acute Ischemic Stroke in a Patient with HOCM, AF, Already on Apixaban 5 mg BID

Continue apixaban 5 mg twice daily without interruption and proceed with standard acute stroke management, including IV thrombolysis if the patient presents within the appropriate time window and meets eligibility criteria. 1

Acute Stroke Management

Thrombolysis Eligibility

• Administer IV tissue plasminogen activator (tPA) if the patient presents within 3 hours of clearly defined symptom onset, provided there are no other contraindications 2, 3
• For patients presenting between 3-4.5 hours, thrombolysis may be considered on a case-by-case basis, though evidence is weaker 3
• The 2012 AHA/ASA guidelines explicitly noted uncertainty about whether patients on novel oral anticoagulants like apixaban can be safely treated with thrombolysis, as this was an unresolved issue at the time of guideline publication 2

Critical Pitfall: Anticoagulation Status

• Do NOT discontinue apixaban for acute stroke management unless thrombolysis is planned 1
• If thrombolysis is administered, apixaban should be held and restarted after 24 hours if follow-up imaging shows no hemorrhagic transformation 1
• Premature discontinuation of apixaban significantly increases the risk of recurrent thrombotic events, which is particularly dangerous in this high-risk patient with AF and recent stroke 1

Post-Acute Phase Anticoagulation Management

Continuing Apixaban After Stroke

• For patients with AF who suffer an ischemic stroke while on therapeutic anticoagulation, continue the same anticoagulant regimen 2
• Apixaban 5 mg twice daily is appropriate for this patient unless they meet dose-reduction criteria (age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL), in which case 2.5 mg twice daily should be used 1
• Do not increase anticoagulation intensity or add antiplatelet agents, as both strategies increase bleeding risk without reducing ischemic events 2

Evidence Supporting Apixaban Continuation

• Apixaban demonstrated superiority over warfarin in the ARISTOTLE trial for stroke prevention in AF patients, with lower rates of stroke, systemic embolism, major bleeding, and mortality 2, 1
• In patients with prior stroke/TIA, apixaban showed consistent benefit regardless of stroke history, with a 7% absolute risk reduction in recurrent stroke over 3.5 years 4
• The AREST trial demonstrated that early apixaban initiation (days 3-5 for small strokes, days 7-9 for medium strokes) was safe, with numerically lower rates of recurrent stroke, death, and symptomatic hemorrhage compared to delayed warfarin 5

Timing of Anticoagulation Restart

If Apixaban Was Held for Thrombolysis

• For small strokes (<1.5 cm): restart apixaban on days 3-5 post-stroke 5
• For medium strokes (≥1.5 cm, excluding full cortical territory): restart apixaban on days 7-9 post-stroke 5
• For large strokes with extensive infarct burden or hemorrhagic transformation: delay anticoagulation beyond 2 weeks 2
• Obtain follow-up brain imaging before restarting anticoagulation to exclude hemorrhagic transformation 5

Bridging Considerations

• Do not use bridging anticoagulation with heparin or LMWH when restarting apixaban, as the short half-life of apixaban (approximately 12 hours) provides rapid therapeutic effect 1, 6
• Bridging is only recommended for patients at particularly high risk (CHADS2 score 5-6, mechanical valves, or stroke within 3 months) when warfarin is used, not for direct oral anticoagulants 2

Additional Stroke Prevention Measures

VTE Prophylaxis During Acute Hospitalization

• Administer prophylactic-dose subcutaneous LMWH or intermittent pneumatic compression devices for patients with restricted mobility 2
• Prophylactic-dose LMWH is preferred over unfractionated heparin 2
• Do not use full-dose anticoagulation for VTE prophylaxis in patients already on therapeutic apixaban 2

HOCM-Specific Considerations

• The presence of HOCM does not alter anticoagulation management for AF-related stroke, as HOCM is not considered a valvular indication that would contraindicate direct oral anticoagulants 2
• Ensure adequate rate control and avoid volume depletion, as these are critical for HOCM management but do not affect anticoagulation decisions 2

Monitoring and Follow-Up

Safety Monitoring

• Monitor renal function regularly, as apixaban is partially renally excreted and dose adjustment is required for severe renal impairment (CrCl <30 mL/min) 1
• Assess for bleeding complications, particularly gastrointestinal bleeding, which is the most common site of major bleeding with anticoagulants 7
• Avoid concomitant NSAIDs, as they significantly increase bleeding risk when combined with anticoagulants 7

Adherence Emphasis

• Counsel the patient on the critical importance of medication adherence, as apixaban's short half-life (12 hours) means that missed doses rapidly lose anticoagulant effect and increase thrombotic risk 2, 6
• If a dose is missed, take it as soon as possible on the same day but do not double the next dose 1