Stroke in atrial fibrillation patients already on oral anticoagulant: What more can be done?

Oral anticoagulants dramatically reduce the risk of embolic stroke in patients with atrial fibrillation (AF). However, each year, 1 to 3 % of patients will present an ischemic stroke despite being on oral anticoagulant. These events can result from efficacy fluctuations, non-cardioembolic stroke, or insufficient efficacy despite appropriate anticoagulation. There are several therapeutic options depending on presumed mechanism of ischemic stroke. However, none of these options has been specifically evaluated in appropriate studies. These options include: reinforcement of education or change in VKA drugs in case of documented therapeutic fluctuations, adjunction of aspirin, change to direct oral anticoagulants, or percutaneous left-appendage closure.