Prevention of Stroke in Atrial Fibrillation

Recommendations for Anticoagulation Therapy

The American College of Cardiology recommends oral anticoagulation with DOACs over antiplatelet therapy for primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation, with a reduction of 48% in intracranial hemorrhage compared to warfarina 1, 5
For patients with a CHA₂DS₂-VASc score ≥2 (men) or ≥3 (women), warfarina is indicated with an INR target of 2.0-3.0, and is preferred in patients with moderate to severe mitral stenosis, mechanical valves, or dialysis 4, 1
DOACs are the first choice for patients with a CHA₂DS₂-VASc score ≥1 (men) or ≥2 (women), with a reduction of 48% in intracranial hemorrhage compared to warfarina, and should be initiated 2-14 days after stroke (low bleeding risk) or >14 days (high bleeding risk) 5, 4
The European Society of Cardiology recommends that DOACs should be used as first-line therapy for stroke prevention in patients with atrial fibrillation, with a Class I/IIa recommendation 4, 5

For patients with a creatinine clearance of 30-49 mL/min, the dose of Dabigatran should be reduced to 110mg 2x/dia, and Rivaroxaban to 15mg 1x/dia 4
For patients with a creatinine clearance of 15-29 mL/min, the dose of Apixaban should be reduced to 2.5mg 2x/dia if ≥2 criteria are met: age ≥80, weight ≤60kg 6

Never use aspirin or DAPT when oral anticoagulation is indicated, as it provides inadequate protection with a similar bleeding risk 1, 2
Do not combine DOAC + antiplatelet therapy beyond the post-ICP period, as it increases bleeding without additional benefit 5, 2
Monitor renal function annually (or 2-3x/year if ClCr 30-50) in patients with DOACs, and prefer Dabigatran 110mg 2x/dia in patients ≥75 years to reduce bleeding 4