Newer Anticoagulants Can Be Used Off-Label
A 77-year-old man with ischemic cardiomyopathy and an ejection fraction of 25% presents with a recurrent embolic-looking stroke while taking aspirin and clopidogrel for a coronary stent placed 6 months ago. Computed tomographic angiography of the head and neck is unrevealing. Telemetry reveals a normal sinus rhythm. Renal functions are normal.
(1) Should one of the newer oral anticoagulant agents be prescribed for this patient?
Off-label use of new oral anticoagulants
What is the diagnosis? Stroke neurologists make use of inductive reasoning, a probabilistic exercise, to determine stroke mechanism. Where ≥1 possible mechanism exists, we typically adopt the philosophy of Occam’s razor, assuming that 1 mechanism is dominant. The ensuing approach to preventive treatment rationally follows the determination of stroke mechanism. The appearance of an embolic-looking stroke on brain imaging usually implies a wedge-shaped cortical infarct or multiple scattered infarcts in one or multiple arterial territories. Embolic stroke may be of arterial, cardiac or less commonly, venous origin (paradoxical embolism).
From the case history, we infer that arteroembolic stroke arising from a ruptured atherosclerotic plaque is less likely given the unrevealing computed tomographic angiogram. We have no immediate evidence of atrial fibrillation (AF), and we assume that the echocardiographic assessment done to determine the low ejection fraction does not show any alternate source …