When is oral anticoagulation indicated for primary and secondary stroke prevention?

Updated: Dec 18, 2018
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Answer

Absolute indications for oral anticoagulation (primary and secondary stroke prevention) include the following:

  • Mechanical heart valve

  • Mitral valve stenosis with any prior embolic event

  • Left atrial myxoma (qualified support from the data)

  • Intraventricular thrombus

  • Ventricular aneurysm with thrombus

  • Mobile thrombus in the ascending

  • Dilated cardiomyopathy (qualified support from the data)

Oral anticoagulation may be considered for patients with a large patent foramen ovale (PFO) under 3 circumstances:

  • Recurrent cerebral ischemia while the patient was receiving aspirin, 300 mg/day

  • Co-occurrence of PFO with atrial septal aneurysm

  • Co-occurrence of PFO with deep venous thrombosis of the leg or abdomen

Other cardiac indications for oral anticoagulation for secondary stroke prevention include the following:

  • Mitral valve prolapse with myxomatous leaflets

  • Rupture of chordae tendineae

  • Dyskinetic ventricular wall segment

  • Mitral ring calcifications

No current evidence-based guidelines address anticoagulation in patients with symptomatic stenoses of extracranial arteries.  The WASID trial showed no benefit to warfarin compared to aspirin in symptomatic intracranial disease. [4]


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