title: Minimizing the risk of hemorrhagic stroke during anticoagulant therapy for atrial fibrillation.
abstract: BACKGROUND
  Oral anticoagulation (OAC) is given for ischemic stroke prevention in patients with nonvalvular atrial fibrillation. OAC's most serious complications are major bleeding and, in particular, hemorrhagic stroke. Together with vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) are now available which have a more rapid onset/offset of action and more predictable anticoagulant effect. The advent of DOAC has given to the clinician an opportunity to tailor OAC therapy in order to maximize advantages and minimize complications.
  
  
  METHODS
  This review covers data published in literature regarding the risk of hemorrhagic stroke in patients taking OAC. Bleeding risk assessment is discussed and different bleeding risk factors are presented. The paper will also review clinical studies comparing DOAC against standard anticoagulation, in regard to the risk of hemorrhagic stroke.
  
  
  CONCLUSIONS
  Bleeding assessment is mandatory in order to select patients at high hemorrhagic risk who will benefit the most from close monitoring. Blood pressure, alcohol intake, concomitant medication and comorbidities should be constantly evaluated and treated accordingly. During VKA therapy, adherence and intensity of anticoagulation must be strictly monitored. DOAC are associated with lower risk of hemorrhagic stroke than VKA. However, periodic hepatic and renal checks as well as careful evaluation of time adherence are necessary to reduce the risk of bleeding.
authors: University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences , Padua , Italy +39 0498215658 ; +39 0498215658 ; vittorio.pengo@unipd.it.
authors: Giacomo
authors: G
authors: Zoppellaro
authors: Serena
authors: S
authors: Granziera
authors: Seena
authors: S
authors: Padayattil Jose
authors: Gentian
authors: G
authors: Denas
authors: Alessia
authors: A
authors: Bracco
authors: Sabino
authors: S
authors: Iliceto
authors: Vittorio
authors: V
authors: Pengo
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D016903:Drug Monitoring / Q000379:methods; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000517:prevention & control; D055118:Medication Adherence; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000139:chemically induced* / Q000517:prevention & control
chemical_list: D000925:Anticoagulants
keywords: atrial fibrillation; direct oral anticoagulants; hemorrhagic stroke; intracranial hemorrhage; oral anticoagulation; vitamin K antagonists