ADD-ONS / MEDICATION

Timing of anticoagulant therapy

Created 23/02/2022, last revision 03/08/2023

Ischemic stroke

in general, immediate anticoagulant therapy is not recommended for patients with acute stroke (AHA/ASA 2019 III/A)
- heparin and low molecular weight heparins (LMWH) in the acute phase either do not reduce the risk of early stroke recurrence, or their subtle effect is counteracted by a higher incidence of bleeding ( FISS-tris) [Wong, 2007]
- this is also true for patients with AFib (IST trial) [Saxena, 2001]
- the risk of bleeding is highest:
  - during the first 10-14 days after the stroke
  - in large infarcts with severe deficits
  - in patients with poorly compensated hypertension
management of the acute stroke patients already receiving anticoagulant therapy is discussed here

acute anticoagulation may be considered in the following scenarios (clinical trials have not shown efficacy):
- intracardiac or aortic thrombosis
- thrombotic stenosis or occlusion of the CCA and ICA – safety and efficacy are unknown (AHA/ASA 2019 IIb/C-LD)
  - dual antiplatelet therapy may be an alternative to anticoagulation in this setting
- TIA patients with AFib

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bridging anticoagulation refers to the administration of a short-acting anticoagulant (usually LMWH) in these situations:
- initiation of anticoagulant therapy
- periprocedural bridging → see separate chapter

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general risk of ICH recurrence ~2-4%/year (without anticoagulation)
risk of ICH recurrence with anticoagulation therapy is increased and depends on the cause of bleeding and the drug used ( DOAC vs. low-dose DOAC vs. warfarin)
- ↑ risk in patients with proven cerebral microbleeds (CMBs) on GRE (if amyloid angiopathy is suspected ⇒ the risk of ICH is increased 7-fold)
- ↑ risk in lobar hematomas (> 4%/year)
- ↑ risk in patients with apolipoprotein E4 (ApoE4)
according to meta-analyses (mainly warfarin trials), the reintroduction of anticoagulation reduces the risk of ischemic stroke without significantly increasing the risk of ICH (Sembill, 2019) [Murthy, 2017]
according to the RETRACE trial (meta-analysis), resumption of anticoagulation therapy improves outcome regardless of the type of hematoma

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