NEUROLOGY OF BODY SYSTEMS

Antithrombotic and interventional treatment options in cardioembolic transient ischaemic attack and ischaemic stroke

D J H McCabe¹, R D Rakhit²

¹ Department of Neurology, The Adelaide and Meath Hospital, Dublin, Trinity College Dublin, Dublin, Republic of Ireland; University Department of Clinical Neurosciences, Royal Free and University College Medical School, Royal Free Hospital, London, UK
² Department of Cardiology, Royal Free and University College Medical School, Royal Free Hospital, London, UK

Correspondence to:
Correspondence to:
D J H McCabe
Department of Neurology, The Adelaide and Meath Hospital Tallaght, Dublin 24, Republic of Ireland;dominick.mccabe{at}amnch.ie

Peer-reviewed data pertaining to anti-thrombotic and interventional therapy for transient ischaemic attack (TIA) or ischaemic stroke patients with non-valvular atrial fibrillation, atrial flutter, interatrial septal abnormalities, or left ventricular thrombus were reviewed. Long-term oral anticoagulant therapy with warfarin is the treatment of choice for secondary stroke prevention following TIA or minor ischaemic stroke in association with persistent or paroxysmal non-valvular atrial fibrillation or atrial flutter. If warfarin is contraindicated, long-term aspirin is a safe, but much less effective alternative treatment option in this subgroup of patients with cerebrovascular disease. Management of young patients with TIA or stroke in association with an interatrial septal defect is controversial. Various treatment options are outlined, but readers are encouraged to include these patients in one of the ongoing randomised clinical trials in this area. It is reasonable to consider empirical anticoagulation in patients with TIA or ischaemic stroke in association with left ventricular thrombus formation following myocardial infarction or in association with idiopathic dilated cardiomyopathy. If warfarin is prescribed, one should aim for a target international normalised ratio of 2.5 (range 2–3) to achieve the best balance between adequate secondary prevention of cardioembolic events and the risk of major haemorrhagic complications.

Abbreviations: APTT, activated partial thromboplastin time; ASD, atrial septal defect; ASA, atrial septal anuerysm; CVD, cerebrovascular disease; INR, international normalised ratio; LAA, left atrial appendage; LMWH, low-molecular-weight heparin; NVAF, non-valvular atrial fibrillation; PFO, patent foramen ovale; TCD, transcranial Doppler; TIA, transient ischaemic attack; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography

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