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Michele Romoli: What is The Optimal Treatment Strategy After Stroke While on DOAC?
Michele Romoli/X
Jan 15, 2026, 13:12

Michele Romoli: What is The Optimal Treatment Strategy After Stroke While on DOAC?

Michele Romoli, Consultant Neurologist at “Bufalini” Hospital, shared on LinkedIn:

”What is the optimal treatment strategy after stroke while on DOAC?

In our latest meta-analysis just published in Neurology, we compared anticoagulation strategies after breakthrough ischemic stroke while on direct oral anticoagulants (DOACs) —a critical clinical challenge affecting thousands of patients worldwide.

KEY FINDINGS:

  • Switching to warfarin increases risk of recurrent stroke (RR 1.80) and intracranial hemorrhage (RR 2.90) vs. continuing the same DOAC.
  • DOAC-based strategies consistently outperformed warfarin.
  • No significant benefit from DOAC-to-DOAC switching or adding antiplatelet therapy.

BOTTOM LINE: Keep patients on DOACs rather than switching to warfarin after breakthrough stroke.

STUDY SCOPE:

  • 8 observational studies, 14,307 patients
  • First comprehensive meta-analysis comparing all major anticoagulation strategies
  • Observational evidence supporting DOAC continuation over warfarin switching

CLINICAL IMPACT:
This research challenges common clinical practices and provides evidence-based guidance for managing one of stroke neurology’s most challenging scenarios—what to do when stroke occurs despite “optimal” anticoagulation.

WHAT’S NEXT:
Excited to announce our upcoming TAILSWITCH study —a feasibility study to guide personalized anticoagulation decisions in breakthrough stroke patients leveraging on plasma DOAC levels.

GRATEFUL to collaborate with an exceptional international team of stroke researchers and neurologists who made this work possible.

Get in touch for TAILSWITCH, and randomize into available RCTs!
1. Carotid Implants for PreveNtion of STrokE ReCurrEnce from Large Vessel Occlusion in Atrial Fibrillation Patients Treated with Oral Anticoagulation (NCT05723926)
2. Early Closure of Left Atrial Appendage for Patients With Atrial Fibrillation and Ischemic Stroke Despite Anticoagulation Therapy (NCT05976685)
3. The Fourth Left Atrial Appendage Occlusion Study (NCT05963698)”

Read the full article here.

Article: Anticoagulation Strategies Following Breakthrough Ischemic Stroke While on Direct Anticoagulants

Authors: Michele Romoli, Maurizio Paciaroni, Nicola Marrone, Lina Palaiodimou, Valentina Tudisco, Claudia Faini, Aristeidis H. Katsanos et al.

Stay updated on all scientific advances with Hemostasis Today.

AFib DOAC Health Hematology Hemostasis Hemostasis News Hemostasis Today LVO Medicine Michele Romoli Neurology RCTs stroke TAILSWITCH thrombosis Warfarin
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