AAN 2026 | Antithrombotic decision-making in stroke, AF, and atherosclerotic disease

It’s a great question, and it’s been a tough, tough situation. Generally, if you have somebody who has atrial fibrillation, is anticoagulated, and has a recurrent event, our approach really is to work to identify the cause of that recurrent event. For instance, if there is severe stenosis in the carotid, which is symptomatic, then the best approach is intervention by surgery or stenting in addition to anticoagulation. There have been now several trials in patients who have atrial fibrillation, have a recurrent event, and have atherosclerosis, either systemic in the coronary arteries or cerebrovascular atherosclerosis. The answer that we have quite clearly from those trials is that adding an antiplatelet to the anticoagulant for atrial fibrillation, those are most commonly factor X inhibitors, results in more bleeding than benefit. What there hasn’t been a trial of is short-term use of antiplatelet therapy. So in that scenario, you had somebody who has, for instance, intracranial atherosclerotic disease, has atrial fibrillation. Is it worthwhile using antiplatelet therapy for 21 to 30 days and then stopping it, which would get you over that initial high-risk period and hopefully would avoid the long-term bleeding risk. But this is going to be an area of ongoing consideration. We don’t yet have evidence to suggest adding antiplatelet therapy to factor X inhibitors in patients with atrial fibrillation is beneficial.

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