Review

. 2025 Apr;20(4):385-400.

doi: 10.1177/17474930241312649. Epub 2025 Jan 30.

Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement

Luciano A Sposato^{1

2

3

4

5}, Alan C Cameron⁶, Michelle C Johansen⁷, Mira Katan⁸, Santosh B Murthy⁹, Micaela Schachter¹⁰, Nicole B Sur¹¹, Shadi Yaghi¹², Sara Aspberg¹³, Valeria Caso¹⁴, Cheng-Yang Hsieh¹⁵, Max J Hilz^{16

17}, Antonia Nucera¹⁸, David J Seiffge¹⁹, Mary N Sheppard²⁰, Sheila Co Martins²¹, M Cecilia Bahit²², Jan F Scheitz²³, Ashkan Shoamanesh²⁴

Affiliations

¹ Department of Clinical Neurological Sciences, Western University, London, ON, Canada.
² Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.
³ Department of Anatomy and Cell Biology, Western University, London, ON, Canada.
⁴ Heart & Brain Lab, Western University, London, ON, Canada.
⁵ Robarts Research Institute, London Health Sciences Centre, University Hospital, Western University, London, ON, Canada.
⁶ School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
⁷ Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁸ Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland.
⁹ Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
¹⁰ Neurocritical Care, Piedmont Healthcare, Atlanta, GA, USA.
¹¹ Department of Neurology, Stroke Division, Miller School of Medicine, University of Miami, Miami, FL, USA.
¹² Department of Neurology, Brown University, Providence, RI, USA.
¹³ Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
¹⁴ Stroke Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy.
¹⁵ Department of Neurology, Tainan Sin Lau Hospital, Tainan.
¹⁶ Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.
¹⁷ Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹⁸ Neurovascular Treatment Unit, Spaziani Hospital, Frosinone, Italy.
¹⁹ Department of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland.
²⁰ Cardiovascular and Genetics Research Institute, St George's, University of London, London, UK.
²¹ Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil.
²² INECO Neurociencias, Rosario, Argentina.
²³ Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin, Berlin, Germany.
²⁴ Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.

PMID: 39719823
PMCID: PMC11951358
DOI: 10.1177/17474930241312649

Review

Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement

Luciano A Sposato et al. Int J Stroke. 2025 Apr.

. 2025 Apr;20(4):385-400.

doi: 10.1177/17474930241312649. Epub 2025 Jan 30.

Authors

Affiliations

¹ Department of Clinical Neurological Sciences, Western University, London, ON, Canada.
² Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.
³ Department of Anatomy and Cell Biology, Western University, London, ON, Canada.
⁴ Heart & Brain Lab, Western University, London, ON, Canada.
⁵ Robarts Research Institute, London Health Sciences Centre, University Hospital, Western University, London, ON, Canada.
⁶ School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
⁷ Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁸ Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland.
⁹ Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
¹⁰ Neurocritical Care, Piedmont Healthcare, Atlanta, GA, USA.
¹¹ Department of Neurology, Stroke Division, Miller School of Medicine, University of Miami, Miami, FL, USA.
¹² Department of Neurology, Brown University, Providence, RI, USA.
¹³ Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
¹⁴ Stroke Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy.
¹⁵ Department of Neurology, Tainan Sin Lau Hospital, Tainan.
¹⁶ Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.
¹⁷ Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹⁸ Neurovascular Treatment Unit, Spaziani Hospital, Frosinone, Italy.
¹⁹ Department of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland.
²⁰ Cardiovascular and Genetics Research Institute, St George's, University of London, London, UK.
²¹ Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil.
²² INECO Neurociencias, Rosario, Argentina.
²³ Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin, Berlin, Germany.
²⁴ Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.

PMID: 39719823
PMCID: PMC11951358
DOI: 10.1177/17474930241312649

Abstract

Background: Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence on this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research.

Methods: We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g. observational versus randomized controlled trial).

Summary: Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data.

Conclusion: Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

Keywords: Atrial fibrillation; anticoagulants; detection; prevention; recommendation; stroke; transient ischemic attack.

PubMed Disclaimer

Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LAS: Speaker/consulting honoraria from Boehringer Ingelheim, Pfizer, Bayer, AstraZeneca, Medtronic; ACC: Speaker honoraria from BMS, Pfizer, AstraZeneca, and Boehringer Ingelheim; MK: Speaker/Consulting honoraria from Astra Zeneca, BMS, Medtronic; NBS: Consulting honoraria from Medtronic; VC: Speaker/consulting honoraria from Boehringer Ingelheim, Pfizer, Bayer, EVER PHARMA, Daiichi Sankyo; C-YH: Speaker honoraria from Boehringer Ingelheim, Daiichi Sankyo, Pfizer, Bayer, Medtronic; MJH: Speaker honoraria from Sanofi; DJS: Speaker/consulting honoraria from Pfizer and AstraZeneca; MCB: Speaker/consulting honoraria from J&J, Anthos Therapeutics, Merck; JFS: Speaker honoraria from BMS, Pfizer, AstraZeneca; AS: Speaker/consulting honoraria from AstraZeneca, Bayer AG, Daiichi Sankyo Ltd, Javelin Inc; other authors: no disclosures relevant to this work.

Figures

**Figure 1.**
Classification of levels of evidence. RCT: randomized controlled trial; IS/TIA/ICH: ischemic stroke, transient ischemic attack or intracranial hemorrhage.

**Figure 2.**
AF risk based on the timing of detection and intensity of cardiac monitoring. AF: atrial fibrillation; ECG: 12-lead electrocardiogram; AFDAS: atrial fibrillation detected after stroke.

**Figure 3.**
Etiological investigation of breakthrough strokes. OAC: oral anticoagulant; AF: atrial fibrillation; LAA: left atrial appendage.

See this image and copyright information in PMC

References

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1. Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: an increasing epidemic and public health challenge. Int J Stroke 2021; 16: 217–221. - PubMed
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1. Jewett GA, Lindsay MP, Goia C, et al.. National trends in hospital admission, case fatality, and sex differences in atrial fibrillation-related strokes. Int J Stroke 2020; 15: 521–527. - PubMed
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Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement

Affiliations

Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement

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Conflict of interest statement

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