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  • Review Article
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Anticoagulant therapy for patients with ischaemic stroke

Nature Reviews Neurology volume 8, pages 319–328 (2012)Cite this article

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Abstract

Anticoagulant therapy for ischaemic stroke aims to prevent recurrent ischaemic stroke and venous thromboembolism. Several large clinical trials have provided insight into the safety and efficacy of anticoagulant therapies. Anticoagulant treatment provides no net benefit over placebo or antiplatelet therapy in patients with acute ischaemic stroke of arterial or cardiac origin, because reductions in early recurrent ischaemic events and venous thromboembolism are offset by increases in bleeding events. For patients with ischaemic stroke of cardiac origin due to atrial fibrillation, long-term warfarin treatment reduces the risk of recurrent stroke by two-thirds compared with control, and by half compared with antiplatelet therapy. New anticoagulants, such as dabigatran, rivaroxaban and apixaban, are as efficacious and safe as warfarin, and have a rapid onset of action, few drug interactions, and predictable anticoagulant effects that do not require routine monitoring. However, the anticoagulant effects of the new drugs cannot be reliably measured or rapidly reversed in the event of major non-compressible bleeding or urgent surgery. In addition, the new agents cannot be used in patients with severe renal impairment or active liver disease. Ongoing research aims to resolve these limitations, examine whether the promising results of clinical trials can be translated into clinical practice, and monitor the long-term safety of anticoagulant therapies.

Key Points

  • Anticoagulant therapy aims to prevent recurrent ischaemic stroke and venous thromboembolism

  • Anticoagulant drugs do not benefit patients with acute ischaemic stroke of presumed arterial or cardiac origin, but long-term treatment with these drugs benefits patients with ischaemic stroke of presumed cardiac origin

  • The oral anticoagulant drug warfarin is inexpensive, widely accepted and effective when used at an optimal dose, but monitoring and adverse reactions are a burden for patients and health-care providers

  • The oral thrombin inhibitor dabigatran and the activated factor X inhibitors rivaroxaban and apixaban are as safe and effective as warfarin, and carry significantly less risk of intracranial haemorrhage

  • The new oral anticoagulant drugs (dabigatran, rivaroxaban and apixaban) have rapid onset of action, few drug interactions and predictable anticoagulant effects that do not require routine monitoring

  • The effects of the new anticoagulant drugs cannot be reliably measured or rapidly reversed, their use is contraindicated in patients with renal impairment, and their long-term safety is unknown

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Figure 1: Schematic illustration of the actions of new anticoagulants in the coagulation cascade.

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  1. Department of Neurology, Royal Perth Hospital, 197 Wellington Street, Perth, 6001, WA, Australia

    Graeme J. Hankey

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Competing interests

G. J. Hankey declares that he has received honoraria from Sanofi-Aventis for serving on the Executive Committees of the AMADEUS and BOREALIS trials, from Bayer and Johnson & Johnson for serving on the Executive Committee of the ROCKET-AF trial, from Merck for serving on the Steering Committee of the TRA 2P TIMI 50 trial, and from the Hamilton Health Sciences Centre for serving on the Stroke outcome adjudication committees of the RE LY and AVERROES trials. He has also received honoraria from and served on the advisory boards of Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, and Pfizer.

Supplementary information

Supplementary Table 1

Methodological characteristics of the clinical trials of the new oral anticoagulants (DOC 61 kb)

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Hankey, G. Anticoagulant therapy for patients with ischaemic stroke. Nat Rev Neurol 8, 319–328 (2012). https://doi.org/10.1038/nrneurol.2012.77

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