Siepen Bernhard M, Seiffge David J, Fischer Urs
Department of Neurology, Inselspital University Hospital Bern and University of Bern.
Graduate School of Health Sciences, University of Bern, Bern.
Curr Opin Neurol. 2022 Feb 1;35(1):55-61. doi: 10.1097/WCO.0000000000001009.
Direct oral anticoagulants (DOAC) are the mainstay of anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation. Persistent uncertainties remain in different areas, and this review discusses current dilemmas based on selected studies.
Optimal timing of DOAC initiation after a recent ischaemic stroke in patients with atrial fibrillation is currently unknown and subject of ongoing randomized controlled trials. Ischaemic stroke despite anticoagulant therapy in patients with atrial fibrillation is frequent, constitutes heterogeneous causes (competing stroke cause, medication error and cardioembolism despite anticoagulation) and optimal treatment is currently unknown. Thorough etiological work-up is justified. Recent randomized controlled trials found no beneficial effect of DOAC therapy in unselected patients with embolic stroke of undetermined source (ESUS). Currently ongoing trials targeting subgroup of ESUS patients with additional atrial cardiopathy will provide novel data. Cerebral mircobleeds combined in a novel risk score (MICON score) provide good predictive value to stratify the risk of intracranial haemorrhage in patients taking anticoagulants. Use of DOAC after intracerebral haemorrhage in patients with atrial fibrillation is subject of ongoing trials.
There are still significant uncertainties in anticoagulant management in patients with stroke. Ongoing trials will soon provide novel data to improve management of these patients.
直接口服抗凝剂（DOAC）是预防非瓣膜性心房颤动患者中风的抗凝治疗的主要手段。不同领域仍存在持续的不确定性，本综述基于所选研究讨论当前的困境。
心房颤动患者近期缺血性中风后启动DOAC的最佳时机目前尚不清楚，是正在进行的随机对照试验的主题。心房颤动患者在接受抗凝治疗时仍频繁发生缺血性中风，其病因多种多样（竞争性中风病因、用药错误和抗凝治疗后的心源性栓塞），目前尚不清楚最佳治疗方法。进行全面的病因检查是合理的。最近的随机对照试验发现，DOAC治疗对未选择的不明来源栓塞性中风（ESUS）患者没有益处。目前正在进行的针对伴有额外心房疾病的ESUS患者亚组的试验将提供新的数据。结合新的风险评分（MICON评分）的脑微出血对服用抗凝剂患者的颅内出血风险分层具有良好的预测价值。心房颤动患者脑出血后使用DOAC是正在进行的试验的主题。
中风患者的抗凝管理仍存在重大不确定性。正在进行的试验很快将提供新的数据，以改善这些患者的管理。
