Table 5.
Summary of recommendations for secondary prevention of recurrent stroke or systemic embolism and other vascular outcomes in patients with non-valvular AF and stroke or TIA.
| Quality of evidence | Strength of recommendation | |
|---|---|---|
| Medical treatment | ||
| We do not recommend antiplatelet agents (single or dual), over no antiplatelet therapy. | Moderate | Weak |
| We recommend VKA therapy over no antithrombotic medication | Moderate | Strong |
| We recommend VKAs (INR 2-3) over antiplatelet therapy. | Moderate | Strong |
| We recommend NOACs over VKAs | High | Strong |
| We suggest NOACs over aspirin in patients who have failed or are unsuitable for VKA therapy. | Moderate | Weak |
| Timing and bridging of medical treatment | ||
| We cannot make recommendations about the optimal time for initiating anticoagulation treatment in patients with acute ischemic stroke.Expert opinion: We suggest antiplatelet therapy in the first 48 h after ischemic stroke associated with AF. We consider it reasonable to start anticoagulant therapy at day 3 or 4 from the index stroke in patients with mild stroke and small infarcts (<1.5 cm) and at day 7 for moderate infarcts. For large infarcts, OACs might be best delayed for 14 days after the index stroke. | Low | Weak |
| We suggest that bridging therapy should be avoided prior to anticoagulation with VKAs or NOACs. | Low | Weak |
| Left atrial appendage occlusion | ||
| We cannot make recommendation on whether LAAO is an acceptable alternative to long-term anticoagulation with either VKAs or NOACs.Expert opinion: LAAO can be considered in individual patients as an alternative to life-long oral anticoagulation after careful weighing of risks and benefits. | Low | Weak |
| (Re-) starting treatment in patients with previous intracerebral haemorrhage | ||
| We cannot make recommendations on whether or not oral anticoagulation should be restarted in patients who have experienced intracerebral haemorrhage.Expert opinion: In patients with AF who have experienced an intracerebral haemorrhage, restarting oral anticoagulation can be considered after careful weighing of risks and benefits. | Low | Weak |
| Medical treatment in specific patient subgroups | ||
| Elderly patients | ||
| In elderly patients we suggest anticoagulant treatment over no anticoagulant treatment and over antiplatelets. | Low | Weak |
| In elderly patients with non-valvular AF and a history of ischemic stroke or TIA, we suggest NOACs over VKAs | Low | Weak |
| Patients with cognitive deficits | ||
| In patients with cognitive decline we suggest anticoagulant treatment over no anticoagulant treatment and over antiplatelets. | Low | Weak |
| In patients with cognitive decline we suggest NOACs over VKAs. | Low | Weak |
| Patients with renal impairment | ||
| In patients with mild (CrCl 50-80 mL/min) or moderate (<50 mL/min) renal impairment we suggest NOACs over VKAs. | Low | Weak |
| Patients with small vessel disease | ||
| In patients with small vessel disease, we cannot make recommendations regarding medical secondary prevention for reducing recurrent stroke or thromboembolism.Expert opinion: In patients with non-valvular AF and previous ischemic stroke or TIA, presence of absence of cerebral microbleeds cannot be used to determine if a patient should be treated with NOACs or VKAs. | Low | Weak |