Anticoagulation for History of Stroke Alone

Key Decision Points

The American College of Chest Physicians recommends that a history of stroke alone does not require heparin infusion or any anticoagulation unless there is a specific indication such as atrial fibrillation, cardioembolic source, or acute venous thromboembolism 1, 2
For patients with noncardioembolic stroke, antiplatelet therapy, not anticoagulation, is the standard treatment, with recommended options including aspirin, clopidogrel, or aspirin/extended-release dipyridamole 1, 2
The American College of Cardiology recommends that oral anticoagulation is not preferred over antiplatelet therapy for noncardioembolic stroke, with Grade 1B evidence 2
For patients with stroke and atrial fibrillation, oral anticoagulation is required, with Grade 1A evidence, and direct oral anticoagulants are preferred over warfarin 1, 2, 3, 4, 5

The American College of Cardiology states that cerebral amyloid angiopathy carries a high risk of recurrent intracranial hemorrhage and generally precludes anticoagulation 3, 4, 5

The American College of Chest Physicians recommends that low-dose subcutaneous heparin for DVT prophylaxis is appropriate for immobilized patients, but this is not therapeutic anticoagulation 1, 2
Prophylactic-dose LMWH or intermittent pneumatic compression should be used for VTE prevention in patients with restricted mobility, started 2-4 days after stroke 2, 6

The American College of Cardiology recommends determining the stroke mechanism to guide anticoagulation therapy, with antiplatelet therapy only for atherosclerotic/noncardioembolic stroke 1, 2
For cardioembolic stroke, oral anticoagulation is required, with DOAC preferred over warfarin 1, 2, 3, 4, 5, 6

The European Heart Journal recommends that small infarcts without hemorrhage can initiate anticoagulation earlier, at 2-4 days 7, 6
The American College of Chest Physicians recommends that large infarcts or hemorrhagic transformation should delay anticoagulation beyond 2 weeks 1, 6
The American College of Cardiology states that TIA without infarction can initiate anticoagulation immediately 3, 4, 5