national-clinical-guidelines-for-stroke-fourth-edition

anticoagulants including direct thrombin inhibitors and factor Xa inhibitors may
ultimately replace warfarin in stroke secondary prevention in patients with creatinine
clearance greater than 30 ml/min. These drugs have a rapid onset of action suggesting a
specific practical advantage following cardioembolic TIA, and have few interactions with
other drugs and food-stuffs, and do not require coagulation monitoring. Due to the lack
of an antidote, patients on such drugs should be excluded from thromboylsis should they
have a stroke, unless, in the case of dabigatran, the prothrombin time (PTT) and
activated partial thromboplastin time (aPTT) are both normal. There are currently no
monitoring tests for rixaroxaban. A NICE technology appraisal recommends dabigatran
as an option for secondary prevention following TIA or ischaemic stroke in patients with
non-valvular AF (National Institute for Health and Clinical Excellence 2012a). However,
in the RE-LY study the benefit of dabigatran over warfarin in the prevention of
thromboembolic events was greatly reduced in centres where the quality of anticoagulant
control was high, assessed by the centre-specific time in the therapeutic range (TTR)
(average TTR in UK centres was 72%; Wallentin et al 2010). Among people with AF not
considered appropriate for warfarin, apixaban was superior to aspirin in the prevention
of thromboembolism, offering an alternative in some specific circumstances (Connolly et
al 2011). Bearing in mind that in all the comparative studies of new oral anticoagulants
with warfarin, participants had to be eligible for both treatments, the existing studies
provide no evidence regarding the safety or efficacy of the new agents in patients where
the bleeding risk is considered to be too high to safely use warfarin.
4.10.1 Recommendations
A Anticoagulation should not be used routinely for the treatment of acute ischaemic
stroke.
B In people with prosthetic valves who have disabling cerebral infarction and who are at
significant risk of haemorrhagic transformation, anticoagulation treatment should be
stopped for 1 week and aspirin 300 mg substituted.
C For patients with ischaemic stroke or TIA in paroxysmal, persistent or permanent
atrial fibrillation (valvular or non-valvular) anticoagulation should be the standard
treatment. Anticoagulation:
● should not be given after stroke or TIA until brain imaging has excluded
haemorrhage
4.10.2 Sources
● should not be commenced in patients with uncontrolled hypertension
● of patients with disabling ischaemic stroke should be deferred until at least 14 days
have passed from the onset; aspirin 300 mg daily should be used until this time
● of patients with non-disabling ischaemic stroke should be deferred for an interval
at the discretion of the prescriber, but no later than 14 days from the onset
● should be commenced immediately following a TIA once brain imaging has ruled
out haemorrhage, using an agent with a rapid onset such as low molecular weight
heparin or an oral direct thrombin or factor Xa inhibitor.
A–B National Institute for Health and Clinical Excellence 2008b
C EAFT (European Atrial Fibrillation Trial) Study Group 1993; consensus
4 Acute phase care
© Royal College of Physicians 2012 51