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Anticoagulation


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Link to RCP Stroke Guidelines 2016 Anticoagulation
  • For people with ischaemic stroke or TIA and paroxysmal, persistent or permanent AF (AF: valvular or non-valvular) or atrial flutter, anticoagulation should be the standard treatment. Anticoagulation: should not be given until brain imaging has excluded haemorrhage; should not be commenced in people with uncontrolled hypertension;
  • for people with disabling ischaemic stroke should be deferred until at least 14 days from onset - aspirin 300 mg daily should be used in the meantime;
  • for people 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 after a TIA once brain imaging has excluded haemorrhage, using an agent with a rapid onset (e.g. low molecular weight heparin or a direct thrombin or factor Xa inhibitor - the latter confined to people with non-valvular AF).
  • People with stroke or TIA in sinus rhythm should not receive anticoagulation unless there is an indication such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection.
  • Anticoagulation for people with TIA or stroke should be with:adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%; or a direct thrombin or factor Xa inhibitor (for people with non-valvular AF).
  • For people with cardioembolic stroke for whom treatment with anticoagulation is considered inappropriate: antiplatelet treatment should not be used as an alternative for people with absolute contraindications to anticoagulation (e.g. undiagnosed bleeding);measures should be taken to reduce bleeding risk, using a tool such as HAS-BLED to identify modifiable risk factors. If after intervention for relevant risk factors the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be used as an alternative; consider a left atrial appendage occlusion device as an alternative.
  • People with recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.