Ischemic stroke while on NOAC therapy in patients with atrial fibrillation: suggested treatment strategies

Data from registries and clinical trials have shown that nonvitamin K oral anticoagulants (NOACs) have a more favorable risk–benefit profile, compared to warfarin in primary and secondary prevention of stroke for patients with non-valvular atrial fibrillation (NVAF). Due to significant reductions in hemorrhagic stroke (RR 0.43, 95% CI 0.29–0.64) and death from any cause (RR 0.87, 95% CI 0.80–0.95), when compared to warfarin at high time in therapeutic range (TTR) levels (more than 70%), NOACs are currently the preferred anticoagulant therapy for NVAF patients [1, 2]. However, in patients prescribed oral anticoagulants, findings from clinical trials have reported annual residual risks (0.7 to 2.3%) in primary and secondary prevention of ischemic event recurrence [3]. Moreover, in the non-randomized RENo-EXTEND study, among those patients with ischemic stroke while on NOAC therapy, findings included a combined rate of thromboembolic and bleeding events equal to 16.7%, corresponding to an annual rate of 13.4% [4]. In light of the above, RCTs are needed to better understand feasible strategies for patients prescribed NOACs with stroke recurrence. The aim of this review is to provide practical suggestions on how to manage this clinical issue.