European Stroke Organisation (ESO) Guidelines on antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation

Published by ESO on May 11, 2021

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The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CJMK is supported by a clinical established investigator grant from the Dutch Heart Foundation (2012T077) and an Aspasia grant from ZonMw (015008048) and is coordinating investigator in the APACHE-AF trial. MP received honoraria as a member of the speaker bureau of Aspen, Sanofi-Aventis, Boehringer Ingelheim, Bayer, Bristol Meyer Squibb, Daiiki Sankyo and Pfizer. EB has received speaker’s honorarium from Bayer and is coordinating investigator in STATICH and national co-coordinating investigator in STROKECLOSE. EK has received speaker’s honoraria from Amgen and BMS/Pfizer, travel grants from Bayer, contributed to advisory board from BMS/Pfizer and is part of the consortium leading PRESTIGE-AF. JK has received speaker’s honorarium from Bayer, Boehringer Ingelheim and Pfizer, and served in advisory board of Boehringer-Ingelheim. JP has received research grants from St. Jude Medical (Abbott) and BMS-Pfizer, served in advisory boards of Bayer, Boehringer-Ingelheim, BMS-Pfizer and MSD, received speaker’s honorary from Abbott, Bayer, Boehringer-Ingelheim and BMS-Pfizer, and is national cocoordinating investigator in STROKECLOSE. DJW is chief investigator for CROMIS-2 and OTPIMAS studies. DJW has received personal fees from Bayer and Amgen, and grant funding from the British Heart Foundation, Stroke Association and the Rosetrees Trust.

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Catharina JM Klijn; Maurizio Paciaroni

Abstract

Patients with ischemic stroke or transient ischemic attack and non-valvular atrial fibrillation have a high risk of recurrent stroke and other vascular events. The aim of this guideline is to provide recommendations on antithrombotic medication for secondary prevention of stroke and other vascular outcomes in these patients. The working group identified questions and outcomes, graded evidence, and developed recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach and the European Stroke Organisation (ESO) standard operating procedure for guidelines. The guideline was reviewed and approved by the ESO guideline board and the ESO executive committee. In patients with atrial fibrillation and previous stroke or transient ischemic attack, oral anticoagulants reduce the risk of recurrence over antiplatelets or no antithrombotic treatment. Non-vitamin K antagonist oral anticoagulants are preferred over vitamin K antagonists because they have a lower risk of major bleeding and death. Recommendations are weak regarding timing of treatment, (re-)starting oral anticoagulants in patients with previous intracerebral haemorrhage, and treatment in specific patient subgroups of those of older age, with cognitive impairment, renal failure or small vessel disease, because of a lack of strong evidence. In conclusion, for patients with atrial fibrillation and ischemic stroke or transient ischemic attack, non-vitamin K antagonist oral anticoagulants are the preferred treatment for secondary prevention of recurrent stroke or thromboembolism. Further research is required to determine the best timing for initiating oral anticoagulants after an acute ischemic stroke, whether or not oral anticoagulants should be (re)started in patients with a history of intracerebral haemorrhage, and the best secondary preventive treatment in specific subgroups.

European Stroke Organisation