Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.

Authors

Ronda Lun, Umberto Pensato, Joseph R Shaw, Carlo A Pivato, Luciano A Sposato, Thalia S Field, Andrew M Demchuk

Published in

BMJ (Clinical research ed.). Volume 394. Pages e084905. Jul 27, 2026. Epub Jul 27, 2026.

Abstract

Ischemic stroke is a serious complication of atrial fibrillation that is associated with substantial morbidity and mortality. For patients with non-valvular atrial fibrillation, treatment with a direct oral anticoagulant (DOAC) is first line treatment for stroke prevention. Ischemic strokes can still occur, however, despite appropriate anticoagulation-an event known as a breakthrough stroke. In this review, we provide an examination of breakthrough stroke through its epidemiology, mechanisms by which breakthrough strokes happen, and a framework for classification. We then propose a systematic, stepwise algorithm to investigate breakthrough stroke, including standardized criteria to identify an ideal population for future clinical trials using the AF-BREACH criteria (Atrial Fibrillation related BReakthrough Embolic Stroke despite appropriate anticoagulation without alternative Cause identified). Lastly, we discuss the emerging evidence for pharmacological and non-pharmacological management strategies.

PMID:
42508832
Bibliographic data and abstract were imported from PubMed on 28 Jul 2026.

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