Anticoagulant Recommendations After Ischemic Stroke

Anticoagulation Based on Stroke Etiology

The American Heart Association recommends oral anticoagulation for patients with ischemic stroke or TIA with non-valvular atrial fibrillation (paroxysmal, persistent, or permanent) 3, 1, 2
Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in non-valvular atrial fibrillation due to better outcomes and lower bleeding risk 1, 2
For patients unable to take oral anticoagulants, aspirin 325 mg/day is recommended, though less effective than anticoagulation 3, 4
For patients receiving vitamin K antagonists who cannot achieve consistent INR levels, switching to a DOAC is preferred 1, 2
For patients with valvular atrial fibrillation (mechanical valve replacement or moderate/severe mitral stenosis), oral anticoagulation with warfarin is recommended 1, 2
For patients with mechanical prosthetic heart valves, oral anticoagulants with an INR target of 3.0 (range 2.5-3.5) are recommended 4, 5, 6
For patients with mechanical mitral valves and previous stroke/TIA, adding aspirin 75-100 mg daily to warfarin (target INR 2.5-3.5) is recommended 1, 2
For patients with bioprosthetic heart valves without other thromboembolism sources, antiplatelet therapy is recommended beyond 3-6 months post-procedure 1, 2, 7

For patients with cerebral venous sinus thrombosis, unfractionated heparin or low molecular weight heparin is reasonable even with hemorrhagic infarction 9
Continuation of anticoagulation with an oral anticoagulant for 3-6 months, followed by antiplatelet therapy is reasonable 9
For patients who develop intracranial hemorrhage, subarachnoid hemorrhage, or subdural hematoma, all anticoagulants and antiplatelets should be discontinued during the acute period (at least 1-2 weeks) 9
Anticoagulant effects should be reversed immediately with appropriate agents (vitamin K, fresh frozen plasma) 9
Oral anticoagulants may be resumed after 3-4 weeks with rigorous monitoring and maintenance of INRs in the lower end of the therapeutic range 9

Patients suitable for anticoagulation should not receive antiplatelets for secondary stroke prevention 1, 2
Adding antiplatelet therapy to anticoagulation increases bleeding risk without reducing ischemic events in most cases 3