Table 1.
Recommendations for patients with cardioembolic stroke types (AHA Guideline 2006).
| Risk factor | Recommendation | Level of evidence |
|---|---|---|
| AF | For patients with ischemic stroke or TIA with persistent or paroxysmal (intermittent) AF, anticoagulation with adjusted-dose warfarin (target INR, 2.5; range, 2.0-3.0) is recommended. | Class I, Level A |
| In patients unable to take oral anticoagulants, aspirin 325 mg/d is recommended. | Class I, Level A | |
| Acute MI and LV thrombus | For patients with an ischemic stroke caused by an acute MI in whom LV mural thrombus is identified by echocardiography or another form of cardiac imaging, oral anticoagulation is reasonable, aiming for an INR of 2.0 to 3.0 for at least 3 mo and up to 1 y. | Class IIa, Level B |
| Aspirin should be used concurrently for the ischemic CAD patient during oral anticoagulant therapy in doses up to 162 mg/d, preferably in the enteric-coated form. | Class IIa, Level A | |
| Cardiomyopathy | For patients with ischemic stroke or TIA who have dilated cardiomyopathy, either warfarin (INR, 2.0 to 3.0) or antiplatelet therapy may be considered for prevention of recurrent events. | Class IIb, Level C |
| Rheumatic mitral valve disease | For patients with ischemic stroke or TIA who have rheumatic mitral valve disease, whether or not AF is present, long-term warfarin therapy is reasonable, with a target INR of 2.5 (range, 2.0-3.0). | Class IIa, Level C |
| Antiplatelet agents should not be routinely added to warfarin in the interest of avoiding additional bleeding risk. | Class III, Level C | |
| For ischemic stroke or TIA patients with rheumatic mitral valve disease, whether or not AF is present, who have a recurrent embolism while receiving warfarin, adding aspirin (81 mg/d) is suggested. | Class IIa, Level C | |
| Mitral valve prolapse | For patients with MVP who have ischemic stroke or TIAs, long-term antiplatelet therapy is reasonable. | Class IIa, Level C |
| Mitral annular calcification | Patients with ischemic stroke or TIA and MAC not documented to be calcific antiplatelet therapy may be considered. | Class IIb, Level C |
| Among patients with mitral regurgitation resulting from MAC without AF, antiplatelet or warfarin therapy may be considered. | Class IIb, Level C | |
| Aortic valve disease | For patients with ischemic stroke or TIA and aortic valve disease who do not have AF, antiplatelet therapy may be considered. | Class IIa, Level C |
| Prosthetic heart valves | For patients with ischemic stroke or TIA who have modern mechanical prosthetic heart valves, oral anticoagulants are recommended, with an INR target of 3.0 (range, 2.5–3.5). | Class I, Level B |
| For patients with mechanical prosthetic heart valves who have an ischemic stroke or systemic embolism despite adequate therapy with oral anticoagulants, aspirin 75 to 100 mg/d, in addition to oral anticoagulants, and maintenance of the INR at a target of 3.0 (range, 2.5–3.5) are reasonable. | Class IIa, Level B | |
| For patients with ischemic stroke or TIA who have bioprosthetic heart valves with no other source of thromboembolism, anticoagulation with warfarin (INR, 2.0–3.0) may be considered. | Class IIb, Level C | |
| Patent foramen ovale | For patients with an ischemic stroke or TIA and a PFO, antiplatelet therapy is reasonable to prevent a recurrent event. | Class IIa, Level B |
| Warfarin is reasonable for high-risk patients who have other indications for oral anticoagulation such as those with an underlying hypercoagulable state or evidence of venous thrombosis. | Class IIa, Level C | |
| Insufficient data exist to make a recommendation about PFO closure in patients with a first stroke and a PFO. PFO closure may be considered for patients with recurrent cryptogenic stroke despite medical therapy. | Class IIb, Level C | |