What is the role of oral anticoagulation in the primary and secondary prevention of stroke?

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 (target INR depending on type and location of valve, mostly 3.0, range 2.5-3.5)

  • Mitral valve stenosis with any prior embolic event (target INR 2.5, range 2-3)

  • Left atrial myxoma (target INR 2.5, range 2-3) (qualified evidence)

  • Intraventricular thrombus (target INR 2.5, range 2-3)

  • Ventricular aneurysm with thrombus (target INR 2.5, range 2-3)

  • Mobile thrombus in the ascending aorta (target INR 2.5, range 2-3)

  • Dilated cardiomyopathy (target INR 2.5, range 2-3) (qualified evidence)

The use of anticoagulation in 2 of those conditions, left atrial myxoma and dilated cardiomyopathy, has only qualified support. Surgical resection is the treatment of choice for left atrial myxoma ; anticoagulation has been used in patients awaiting surgical resection, but this strategy is controversial at best. [41, 42] )

Although dilated cardiomyopathy has been considered an indication for anticoagulation, currently no data from randomized clinical trials support this assertion. A European study, the Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial, failed to show superiority of warfarin over aspirin. The American counterpart of WATCH, the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction study (WARCEF), also showed no benefit to the use of warfarin.


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