When to Start Oral Anticoagulant Therapy Post-Stroke: From Common to Rare Conundrums

This review summarizes recent evidence on when to start oral anticoagulant therapy following stroke, including both common and rare clinical conundrums.

While previous recommendations based on Diener's rule suggested waiting up to 12 days based on stroke severity and neuroradiological findings, newer data support earlier initiation or resumption of anticoagulation, particularly for mild and moderate ischemic strokes, generally within 4 days. In patients with a history of intracerebral hemorrhage, anticoagulation resumption involves weighing thromboembolic risk against recurrent hemorrhage risk, requiring individualized decisions regarding whether and when anticoagulation should be resumed. Clinical recommendations for post-stroke anticoagulation emphasize early, individualized initiation of direct oral anticoagulants for mild-to-moderate ischemic strokes based on neuroimaging. After intracerebral hemorrhage, anticoagulation is generally restarted within 4 to 8 weeks for atrial fibrillation, with earlier resumption potentially warranted in selected high-thromboembolic-risk patients, particularly those with mechanical heart valves.