Anticoagulant therapy as a part of secondary stroke prevention in patients with atrial fibrillation

Abstract

Atrial fibrillation (AF) is the main cause of cardioembolic ischemic stroke (IS), it occurs in 25–35% of patients with IS, and its presence increases the risk of recurrent stroke compared with patients with sinus rhythm. The main method of preventing recurrent IS in AF is the administration of oral anticoagulants (OACs); in non-valvular AF, direct OACs (DOACs) have an advantage. Meta-analysis of randomized clinical trials showed a 19% greater reduction of stroke and systemic embolism risk in the DOACs group compared to warfarin (p<0.0001), including a 51% greater hemorrhagic stroke (HS) risk reduction (p<0.0001). In an additional sub-analysis of the ARISTOTLE trial, patients with AF and a history of stroke/transient ischemic attack showed a significant reduction in the risk of all types of strokes and HS. Although no randomized trial explored the direct comparisons of drugs from the DOACs group, data from observational studies indicate the potential advantage of apixaban in terms of reducing the risk of IS. Russian 2020 clinical guidelines for AF treatment suggest that the resumption/initiation (1–3–12 days) of anticoagulant therapy after an IS should be determined by the decision of a multidis ciplinary team (neurologist, cardiologist, neuroimaging specialist) based on recurrent IS and bleeding risk assessment. According to the 2020 guidelines of the Ministry of Health, the resumption of OACs therapy after an intracranial hemorrhage in patients with AF may be recommended 4–8 weeks after the event, and the decision to reinitiate therapy, as well as after IS, should be made by a multidisciplinary team.

Keywords

• ischemic stroke
• intracranial hemorrhage
• secondary prevention
• atrial fibrillation
• direct oral anticoagulants
• apixaban