What is the role of anticoagulation in the primary stroke prevention after myocardial infarction (MI)?

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

Anticoagulation (target INR 2.5, range 2-3) for primary stroke prevention after MI is recommended in patients with the following risk factors [3] :

  • Persistent or paroxysmal atrial fibrillation

  • Left ventricular thrombus

  • Left ventricular aneurysm

  • Consider in extensive wall motion abnormalities resulting in a left ventricular ejection fraction (LVEF) < 25%. While the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial did not show benefit for warfarin compared to aspirin, a WARCEF exploratory analysis showed that prior stroke and EF < 15% were risk factors recurrent for ischemic stroke. [38]  It is unknown whether warfarin reduces stroke risk in this population. 

The optimal duration of anticoagulation in these patients is debatable. A meta-analysis of studies published between 1960 and July 1999 showed that two thirds of patients with coronary artery disease were treated with oral anticoagulation for longer than 2 years. [39] Usually, administering oral anticoagulation according to the indications already listed is recommended as long as the causing condition persists and no contraindications emerge.


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