Dealing with oral anticoagulants in stroke patients: A narrative review based on current practice guidelines

A significant subgroup of stroke patients require oral anticoagulants (OACs) for the prevention of recurrence of thromboembolic events. For a long time, clinicians have been using conventional warfarin as OAC in stroke prevention. However, the discovery of newer OACs that do not require strict monitoring with an international normalized ratio (INR) has resulted in changes in guidelines for stroke prevention. For the last 10 years, there has been a flood of literature on the use of Vitamin K antagonist (VKA) versus non-vitamin K antagonist oral anticoagulants (NOACs) in stroke prevention. More than 100 meta-analyses, randomized trials, and more than six new guidelines or comparisons of guidelines are available in the medical literature. Hence, we have planned to write a review on this topic to compile all new findings and recommendations. Therefore, now, clinicians have to use currently available knowledge and guidelines for choosing appropriate OAC in stroke settings. The current review is divided into 6 segments: 1) general information and protocol for VKA use; 2) current definition to describe "valvular" versus "non-valvular" AF; 3) to describe current recommendations for uses of VKA and NOACs for recurrent stroke prevention; 4) how to use VKA/NOACs in special populations; 5) perioperative management of patients on OAC; and 6) OAC recommendations for Asian population. This narrative review can help for the better understanding and clear clinical decision making for selection of OAC in stroke patients. Further, it will highlight the gray areas with no clearcut guidance for the selection of OAC.