When can a direct oral anticoagulant (DOAC) be started in a patient with severe mitral stenosis and a history of stroke after an intracranial hemorrhage (ICH)?

When to Start DOAC After Intracranial Hemorrhage in Severe Mitral Stenosis

Critical First Point: DOACs Are Contraindicated in This Patient

You cannot use a DOAC in a patient with severe mitral stenosis—warfarin is the only appropriate anticoagulant for this condition. 1, 2

Anticoagulant Selection

• Warfarin with target INR 2.0-3.0 is mandatory for patients with moderate-to-severe mitral stenosis and atrial fibrillation, regardless of stroke history 1, 2
• Direct oral anticoagulants (DOACs) are absolutely contraindicated in moderate-to-severe mitral stenosis per ESC guidelines with Class I, Level A evidence 1, 2
• This contraindication exists because pivotal DOAC trials specifically excluded patients with moderate-to-severe mitral stenosis, and the valve pathophysiology creates unique thrombogenic conditions 2, 3

Timing of Anticoagulation Restart After ICH

Wait at least 4 weeks after the intracranial hemorrhage before restarting anticoagulation 4, 5

Specific Timeline Algorithm:

• Acute phase (0-48 hours): Absolutely avoid anticoagulation—risk of hemorrhagic expansion is highest 4, 5
• Early phase (48 hours to 4 weeks): Continue to withhold anticoagulation 4, 5
• Standard restart window (4-8 weeks): This is the recommended timeframe for most patients 4, 5
• Extended delay (>8 weeks): Consider for larger hemorrhages or lobar ICH with suspected cerebral amyloid angiopathy 5

Risk Stratification Before Restart

Assess ICH Recurrence Risk:

• Lobar ICH location: Higher recurrence risk, associated with cerebral amyloid angiopathy—consider longer delay or alternative strategies 4, 5
• Deep hemispheric ICH: Lower recurrence risk, typically hypertensive arteriopathy—more favorable for anticoagulation restart 5
• MRI findings: Presence and number of cerebral microbleeds increases recurrence risk 5

Assess Thromboembolic Risk:

• This patient has extremely high thromboembolic risk due to the combination of severe mitral stenosis, atrial fibrillation, and prior stroke (CHA₂DS₂-VASc score ≥4) 4, 2
• Annual stroke risk without anticoagulation exceeds 7% in this population 5, 2

Pre-Restart Requirements

• Obtain follow-up neuroimaging (CT or MRI) before restarting anticoagulation to confirm hemorrhage stability 4
• Optimize blood pressure control to target <130/80 mmHg before restart 5
• Ensure no uncontrolled hypertension as this is a modifiable bleeding risk factor 1, 5

Warfarin Initiation Protocol

• Start warfarin at 2-5 mg daily without loading doses to minimize hemorrhagic complications 2
• Target INR 2.5 (range 2.0-3.0) 1, 2
• Check INR weekly during initiation, then monthly once stable 2
• Avoid bridging with heparin or low-molecular-weight heparin in the acute post-ICH period as this increases symptomatic intracranial hemorrhage risk 4

Alternative Strategy for Very High ICH Recurrence Risk

• Left atrial appendage occlusion should be considered if the patient has probable cerebral amyloid angiopathy or other features suggesting very high ICH recurrence risk 4, 5
• This mechanical approach provides stroke prevention without systemic anticoagulation 4

Common Pitfalls to Avoid

• Never restart anticoagulation within 48 hours of ICH—this dramatically increases hemorrhagic expansion risk 4, 5
• Never use DOACs in moderate-to-severe mitral stenosis despite their lower ICH risk in other populations 1, 2
• Do not use antiplatelet therapy alone as stroke prevention—it is insufficient in severe mitral stenosis 2
• Do not delay indefinitely in patients with deep ICH and controlled blood pressure—the ischemic stroke risk outweighs recurrent ICH risk after 4-8 weeks 4, 5