Newer Oral Anticoagulants: Stroke Prevention and Pitfalls

Anand Patel1, *, Richard P. Goddeau Jr1, Nils Henninger1, 2
1 Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
2 Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA

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© Patel et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (, which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North, Worcester, MA 01655, USA; Tel: (508) 334-2527; Fax: (508) 856-6778; Email:


Warfarin is very effective in preventing stroke in patients with atrial fibrillation. However, its use is limited due to fear of hemorrhagic complications, unpredictable anticoagulant effects related to multiple drug interactions and dietary restrictions, a narrow therapeutic window, frequent difficulty maintaining the anticoagulant effect within a narrow therapeutic window, and the need for inconvenient monitoring. Several newer oral anticoagulants have been approved for primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation. These agents have several advantages relative to warfarin therapy. As a group, these direct oral anticoagulants (DOAC), which include the direct thrombin inhibitor, dabigatran, and the factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), are more effective than dose adjusted warfarin for prevention of all-cause stroke (including both ischemic and hemorrhagic stroke), and have an overall more favorable safety profile. Nevertheless, an increased risk of gastrointestinal bleeding (with the exception of apixaban), increased risk for thrombotic complication with sudden discontinuation, and inability to accurately assess and reverse anticoagulant effect require consideration prior to therapy initiation, and pose a challenge for decision making in acute stroke therapy.

Keywords: Atrial fibrillation, hemorrhage, ischemic stroke, oral anticoagulation, outcome, review, therapy, thrombolysis.