Thromb Haemost 2021; 121(06): 716-730
DOI: 10.1055/s-0040-1721665
Review Article

Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects

A. John Camm
1  Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
Dan Atar
2  Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
3  University of Oslo, Oslo, Norway
› Author Affiliations
Funding This study was supported by Bayer.


Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.

Publication History

Received: 16 July 2020

Accepted: 31 October 2020

Publication Date:
07 January 2021 (online)

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