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Management of Cardioembolic Stroke 159

ANTICOAGULATION IN ELDERLY: NOVEL ORAL ANTICOAGULANTS (NOAC S) : They
are the oral direct thrombin inhibitors dabigatran ,
WASPO and BAFTA trials have shown that OAC is
safe even in octagenerians. Algorithm for anticoag- oral direct factorXa inhibitors rivaroxaban, apxiaban.
ulation in elderly (Fig 3) INR should be than 2 when switching from VKA to
NOAC because of rapid onset of action. Renal func-
ANTICOAGULATION IN STROKE tion should be normal on changing from NOAC to
PREVENTION VKA with an 2-3 day overlap.

RHYTHM ABNORMALITIES : Atrial fibrillation is the 150 mg b.i.d of dabigatran is preferred to110 mg b.i.d.,
commonest significant cause with its incidence in- with the latter dose given in:
creasing with age, and tends to produce severe dis- • elderly patients, age ≥80
abiling strokes. It is associated with 5 fold increase
risk of stroke and a 3 fold increase of congestive • concomitant use of interacting drugs (e.g. ver-
cardiac failure with frequent hospitalizations . It can apamil)
be valvular or non valvular, paroxysmal ,.persistent • high bleeding risk (HAS-BLED score 3)
or permanent. Its pertinent to decide assiduously
thromboprophylatic therapy as it needs to balance • moderate renal impairment (CrCl 30-49 mL/min).
the risk of stroke against the risk of major bleeding, Rivaroxaban in a dose of 20 mg o.d. is preferenced
ICH,which is the most dreaded complication of anti- to15 mg o.d., with the latter dose given in:
coagulation therapy. (Fig 4)
• high bleeding risk (HAS-BLED score ≥3)
Thromboembolic risk stratification is based on
CHA2DS2VASc score and has been validated in mul- • moderate renal impairment (CrCl 30-49 mL/min)
tiple trials . Prediction accuracy of it in stratifying truly Choice of anticoagulant should be discussed with the
low risk patients with non valvular atrial fibrillation patient and care giver and documented
is valuable in evaluating those who are unlikely to
benefit from oral anticoagulant therapy. HAS BLED is Mitral Stenosis, Mitral Regurgitation, Mitral
a simple bleeding assessment score than the more Prolapse, Mitral Annular Calcification, and
complicated scores like HEMORR2HAGES score or
ATRIA score and allows the physician to decide the Aortic Valve Disease Recommendations :
correctable risk factors for bleeding. The risk of cardioembolism is multifactorial and de-
pends on location of the valve , severity of the dis-
AHA /ASA /ESC GUIDELINES : Nonvalvular AF pa- ease and underlying pathology. Long-term VKA ther-
tients with prior stroke, or transient ischemic attack , apy ( target INR of 2.5 range, 2.0– 3.0) is recommend-
or a CHA2 DS2 -VASc score of 2 or greater in males, ed in rheumatic mitral valvular disease and AF who
CHA2 DS2 -VASc score of 3 or greater in females develop ischemic stroke or TIA, (1A). Patients with
oral anticoagulants are recommended. Options in- rheumatic mitral valve disease without AF ,develop
clude warfarin (INR 2.0 to 3.0)( 1 A), or NOACs (1 B).
ischemic stroke or TIA due to other causes long-
INR is checked weekly and later monthly time in term VKA therapy (INR target of 2.5 , range 2.0–3.0)
therapeutic range TTR should be kept as high as pos- may be considered instead of antiplatelet therapy (
sible at the start of antithrombotic therapy. (1 A) . Non- IIb; C). Rheumatic mitral valve disease patients who
valvular AF patients unable to maintain a therapeutic are on VKA therapy after an ischemic stroke or TIA,
INR level with warfarin, use of NOAC is recommend- antiplatelets should not be prescribed as a routine
ed. ( I C) . Periodic monitoring type of antithrombot- .(III; C). Patients with rheumatic mitral valve disease
ic therapy is recommended to reassess stroke and while on adequate VKA therapy develop an ischemic
bleeding risks. (1C). stroke or TIA, aspirin may be added.( IIb; C). Native
aortic or nonrheumatic mitral valve disease patients
Baseline renal function and annual reevaluatuion without AF or an indication for anticoagulation, de-
should be done in patients on NOAC . (1 B). In atrial velop an ischemic stroke or TIA antiplatelet therapy
flutter, antithrombotic therapy is recommended as is recommended ( I C).
for AF. (1C). No antithrombotic therapy for patients
with nonvalvular AF patients with a CHA2 DS2 -VASc
score of 0. (11a, B). Combination of oral anticoagu- PROSTHETIC MECHANICAL AND
lants and antiplatelets is avoided in AF patients due BIOPROSTHETIC VALVES
to bleeding risk unless there is an indication for Anticoagulation with a VKA and (INR) monitoring is
platelet inhibition (111 B). recommended .Aspirin 75-100 mg/d is recommend-

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