WSC 2026 | Stepwise workup for breakthrough stroke: guidance for neurologists
Ronda Lun, MD, MSc, FRCPC, University of Calgary, Calgary, Canada, comments on the stepwise workup for a patient who has had a stroke while on a direct oral anticoagulant (DOAC), emphasizing the importance of a thorough clinical history, evaluation of drug indication and dose, and consideration of potential interactions and other etiologic mechanisms of stroke. Dr Lun highlights the need to assess factors such as missed doses, intentional interruptions, renal function, and drug-food interactions, as well as the evaluation of vessel imaging and vascular risk factor profile. This interview took place at the 18th World Stroke Congress (WSC) in Seoul, Korea.
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Transcript
So I think as with any important clinical problem, we always start with the patient first. So getting a very thorough clinical history, including things like were they missed doses, were they taking their medications perhaps not on time, which can sometimes result in not normal levels throughout. And also, you know, were there intentional interruptions? That’s the first step. The second step is to evaluate the indication of the drug as well as the dose based on things like renal function and weight, as well as their increased risk for bleeding...
So I think as with any important clinical problem, we always start with the patient first. So getting a very thorough clinical history, including things like were they missed doses, were they taking their medications perhaps not on time, which can sometimes result in not normal levels throughout. And also, you know, were there intentional interruptions? That’s the first step. The second step is to evaluate the indication of the drug as well as the dose based on things like renal function and weight, as well as their increased risk for bleeding. Then to look for specific interactions that may lower the drug level in the blood, as well as drug-food interactions. A lot of people don’t know that rivaroxaban must be taken with food because that increases the absorption of the drug by about 15 to 20%, which is pretty significant when you think about it. And then next, to look for other etiologic mechanisms of stroke, for example, getting vessel imaging, to look for atherosclerosis, and then also considering their other vascular risk factor profile and then looking for specific causes of hypercoagulability, for example, a really malignant cancer and also antiphospholipid antibody syndrome.
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