Antithrombotic therapy in primary and secondary stroke prevention of cardiac patients and in acute stroke

Abstract

Primary vascular prevention: the prevalence of cardiogenic stroke will increase in the future. All patients with atrial fibrillation but without any ischemic stroke, must undergo a rigorous risk evaluation, which is crucial for pharmacotherapy. Atrial fibrillation is an important risk factor for stroke, therefore patients with atrial fibrillation should be anticoagulated (except those without other risk factors). Even patients over 75 years with atrial fibrillation could be anticoagulated if the INR is properly controlled. The authors review also the role of anticoagulation in patients suffering from myocardial infarction or valve diseases. Acute stroke: The new European stroke guideline does not recommend the use of conventional or fractionated heparin in the first three days of acute stroke, but aspirin therapy is recommended. Long-term anticoagulation is needed only if cardiac source of emboli can be verified, the patient has good compliance, and the risk of hemorrhagic complication is low (INR: 2-3). Otherwise, antiplatelet therapy is recommended. Some authors recommend early anticoagulation in special cases (high risk of embolisation, left atrial/ventricular thrombus, arterial dissection or surgical intervention for a severe arterial stenosis). Caution is needed in patients with large infarct, uncontrolled hypertension and microbleeds on MRI. Secondary prevention: Antiplatelet therapy is recommended for every post-stroke patient, but for those with cardiac source of emboli anticoagulation is recommended.