Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

  • Luca Masotti | luca.masotti@tin.it Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, San Giuseppe Hospital, Empoli (FI), Italy.
  • Elisa Grifoni Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, San Giuseppe Hospital, Empoli (FI), Italy.
  • Alessandro Dei Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, San Giuseppe Hospital, Empoli (FI), Italy.
  • Vieri Vannucchi Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy.
  • Federico Moroni Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy.
  • Grazia Panigada Internal Medicine and Stroke Unit, SS. Cosma and Damiano Hospital, Pescia (PT), Italy.
  • Stefano Spolveri Internal Medicine and Stroke Unit, Borgo San Lorenzo Hospital, Florence, Italy.
  • Giancarlo Landini Internal Medicine, Stroke Unit and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy.

Abstract

The balance between the risk of early stroke recurrence and hemorrhagic transformation represents the cornerstone of practical management of non-valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS). Patients who receive antithrombotic therapy as secondary prevention in the early phase of NVAF-related AIS have a better prognosis compared with patients who do not receive antithrombotic treatment. Recently, the RAF study showed that the best efficacy/safety profile was associated with anticoagulation started between 4 and 14 days from stroke onset. Based on the RAF study, the 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest starting anticoagulants between 4 and 14 days from stroke onset with a class of recommendation IIa. Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. However, the real life evidence suggests that early starting time of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality. In the present review the Authors provide an update on anticoagulation in the early phase of NVAF-related AIS with focus on DOACs.

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Published
2019-01-03
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Issue
Section
Reviews
Keywords:
Stroke, dabigatran, rivaroxaban, apixaban, edoxaban, direct oral anticoagulants.
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How to Cite
Masotti, L., Grifoni, E., Dei, A., Vannucchi, V., Moroni, F., Panigada, G., Spolveri, S., & Landini, G. (2019). Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?. Italian Journal of Medicine, 13(1), 24-31. https://doi.org/10.4081/itjm.2019.1111