Study: Single Anticoagulant Safer for Stroke Survivors

 Will this change your doctor's protocol on stroke prevention? Does your doctor even know about this? 

Study: Single Anticoagulant Safer for Stroke Survivors

Physicians have long debated whether patients at high risk for stroke should be treated with one type of antithrombotic agent (an anticoagulant) or a combination of two (an anticoagulant plus an antiplatelet drug, such as aspirin).

A Japanese study published in JAMA Neurology has shown that using a single antithrombotic agent may be safer and just as effective for patients who have survived a stroke and also have both nonvalvular atrial fibrillation and atherosclerosis.

Although treatment with both drugs might seem like a good way to prevent another stroke or heart attack, this approach also raises the risk for serious bleeding. To determine whether the added protection against strokes outweighs the increased risk for bleeding, researchers conducted a large clinical trial across 41 medical centers in Japan. They enrolled 316 patients who had experienced an ischemic stroke or a transient ischemic attack in the preceding year. All patients had nonvalvular atrial fibrillation, increasing their risk for stroke, and also had signs of atherosclerosis, such as peripheral artery disease or intracranial or carotid artery stenosis.

The patients were randomly assigned to two groups: one group received an anticoagulant alone, and the other group received the anticoagulant plus an antiplatelet drug.

The researchers monitored patients for up to 2 years to assess them for new strokes, heart attacks, or serious bleeding problems. Results indicated that the number of patients who had another stroke or major cardiovascular event was about the same in both groups: approximately 18% of those receiving combination therapy and 20% of those receiving monotherapy. However, serious bleeding was much more common in the combination therapy group. Nearly one in five patients treated with two antithrombotic agents had major or medically significant bleeding, compared with fewer than one in ten patients treated with monotherapy. Because the added stroke protection was minimal, but the bleeding risk was clearly greater, the study was stopped early.

This study suggests that for stroke survivors who also have nonvalvular atrial fibrillation and atherosclerosis, treatment with a single anticoagulant may be the safer and smarter choice. Adding a second drug did not reduce the risk for new strokes enough to justify the higher risk of bleeding. In some cases, combination therapy might still be needed, for example, after heart stent placement, but for most people in this situation, monotherapy may be the best option.

References

Okazaki S, et al. JAMA Neurol. 2025:e253662. doi:10.1001/jamaneurol.2025.3662