Atrial Fibrillation: Post-Stroke

Key points

• AF with acute ischaemic stroke or TIA: a DOAC is the anticoagulant of choice under NICE NG196 — this replaces the older advice that warfarin was the agent of choice · a vitamin K antagonist only if a DOAC is contraindicated, not tolerated or unsuitable.
• After a TIA with AF, anticoagulation can be started once imaging has excluded haemorrhage — there is no need to wait 2 weeks.
• After an acute ischaemic STROKE with AF, and once haemorrhage is excluded on imaging, anticoagulation is usually deferred for about 2 weeks, giving aspirin 300 mg in the interim.
• Delay anticoagulation further if imaging shows a large cerebral infarct, because of the risk of haemorrhagic transformation · discuss timing with the stroke team.
• Aspirin or aspirin-dipyridamole should not be used for AF-related stroke prevention — use them only if there is a separate indication.

Decision points in this pathway

• Haemorrhage on imaging?
• TIA rather than completed stroke?
• Large cerebral infarct on imaging?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.