Potential new uses of non-vitamin K antagonist oral anticoagulants to treat and prevent stroke.

Abstract

Non-vitamin K antagonist oral anticoagulant (NOAC) drugs are at least equivalent to warfarin for ischemic stroke prevention in patients with atrial fibrillation and have a lower risk of intracranial hemorrhage. The role of these agents in the prevention and treatment of other types of cerebrovascular disease remains unclear. We reviewed the literature (randomized trials, exploratory comparative studies, and case series) on the use of NOACs in patients with atrial fibrillation, venous thromboembolism, and cerebrovascular disease independent of atrial fibrillation. The literature on the use of NOACs for treatment and prevention of cerebrovascular disease in patients without atrial fibrillation is sparse. The potential benefit of vitamin K antagonists over antiplatelet agents for primary and secondary prevention in certain subsets of patients with cerebrovascular disease is offset by the increased risk of major and intracranial hemorrhage. Given that NOACs are equivalent to vitamin K antagonists in preventing ischemic stroke and systemic embolism in patients with atrial fibrillation with less bleeding risk, clinical trials are needed to investigate the short- and long-term use of NOACs in populations of patients with other forms of cerebrovascular disease, including those with cryptogenic stroke with or without evidence of patent foramen ovale and low ejection fraction, cervical artery dissection, large artery atherosclerosis, venous thrombosis, and stuttering lacunar stroke. There may be a role for NOACs in stroke prevention and treatment beyond atrial fibrillation. Randomized controlled trials are needed to compare NOACs to current stroke prevention and treatment strategies in certain subgroups of patients with cerebrovascular disease.