Management of Acute Ischemic Stroke with Intracranial Carotid Stenosis and Atrial Fibrillation

Recommended Antithrombotic Strategy

The American College of Chest Physicians recommends that combination therapy with dabigatran 150mg twice daily and aspirin 75mg is not used for a patient with acute ischemic stroke, intracranial carotid stenosis of 60%, and atrial fibrillation due to significantly increased bleeding risk without proven additional benefit 1, 2
For patients with acute ischemic stroke and atrial fibrillation, oral anticoagulation should generally be initiated within 1-2 weeks after stroke onset, not immediately, as recommended by the American College of Chest Physicians 3
The European Society of Cardiology guidelines recommend that oral anticoagulation is strongly recommended over no antithrombotic therapy, aspirin alone, or combination therapy with aspirin and clopidogrel for patients with ischemic stroke and atrial fibrillation 3, 4
Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended over vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation, according to the American College of Chest Physicians 1

The American College of Chest Physicians strongly recommends against antiplatelet therapy alone (monotherapy or aspirin in combination with clopidogrel) for stroke prevention in atrial fibrillation 1
The European Society of Cardiology guidelines specifically state that after a TIA or stroke, combination therapy of oral anticoagulation and an antiplatelet is not recommended due to increased bleeding risk without additional benefit in stroke prevention (Class III harm, Level B evidence) 2

The American College of Chest Physicians recommends initiating dabigatran 150mg twice daily as monotherapy after an appropriate delay (typically 1-2 weeks after stroke onset) for patients with acute ischemic stroke and atrial fibrillation 3, 5
The American College of Chest Physicians recommends that the 150mg twice daily dose is preferred over the 110mg dose due to superior efficacy in preventing recurrent stroke, especially important in a patient who has already had a stroke 1, 5

The American Heart Association recommends avoiding immediate anticoagulation after acute stroke due to risk of hemorrhagic transformation, and the size of the infarct should guide the timing of anticoagulation initiation - larger infarcts require longer delays before starting anticoagulation 3
The European Society of Cardiology recommends that thrombolytic therapy with rtPA is not recommended if the patient is taking dabigatran and has an abnormal aPTT 2