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Matteo Foschi: When Should We Restart Anticoagulation After a Breakthrough Ischemic Stroke?
Matteo Foschi/LinkedIn
Jun 21, 2026, 16:53

Matteo Foschi: When Should We Restart Anticoagulation After a Breakthrough Ischemic Stroke?

Matteo Foschi, Neurologist at Azienda USL della Romagna, Affiliated Researcher at the Cochrane MS and Rare Diseases of the CNS Review Group, shared a post on LinkedIn about a recent article he and his colleagues co-authored, published in International Journal of Stroke, adding:

“When should we restart anticoagulation after a breakthrough ischemic stroke?

Patients who experience an ischemic stroke despite ongoing oral anticoagulation represent one of the most challenging and understudied populations in stroke medicine.

While recent randomized trials have informed DOAC timing after AF-related stroke, evidence for breakthrough stroke has remained limited.

I am happy to share our latest work from the ASPERA-R Study, published today on International Journal of Stroke:

A Target Trial Emulation framework with a cloning–censoring–weighting approach to compare early versus delayed DOAC resumption after breakthrough ischemic stroke.

Key findings

Early, severity-adapted DOAC initiation was associated with:

  • 56% lower risk of new ischemic events at 90 days (HR 0.43)
  • Lower moderate-to-severe bleeding risk (RR 0.10)
  • 62% lower all-cause mortality (RR 0.38)
  • 69% lower vascular mortality (RR 0.31)
  • A consistently positive Net Early Benefit Score (NEBS) across all stroke severity categories.

Why these matters

Patients with breakthrough stroke face a particularly high risk of early recurrence.

Our findings suggest that early DOAC resumption may reduce recurrent ischemic events and mortality without increasing major bleeding, supporting a more proactive secondary prevention strategy in this high-risk population.

This study also demonstrates how target trial emulation can generate clinically meaningful evidence when randomized trials are lacking.

As always, my sincere thanks to all the ASPERA PIs and collaborators.”

Title: Early versus Late starting of Direct Oral Anticoagulants after breakthrough ischemic stroke: A Target Trial Analysis from the ASPERA-R Study

Authors: Lucio D’Anna, Matteo Foschi, Francesca Gabriele, Raffaele Ornello, Andrea Zini, Matteo Paolucci, Stefano Forlivesi, Mauro Gentile, Giacomo Urbinati, Angelo Cascio Rizzo, Maria Sessa, Ghil Schwarz, Rachele Tortorella, Gabriele Prandin, Soma Banerjee, Gaurav Desai, Leonardo Pantoni, Francesco Mele, Giuseppe Scopelliti, Ilaria Cova, Mariarosaria Valente, Domenico Maisano, Luca Antonelli, Maria Rosaria Bagnato, Giovanni Di Mauro, Francesca Bernocchi, Martina Gaia Di Donna, Barbara Casolla, Myriam Perla Mazloum, Kristina Kacani, Djeghlal Noufel-Anis, Laura Gonzalez-Martín, Ricardo Rigual, Blanca Fuentes, Carlos Hervás, Paolo Candelaresi, Vincenzo Andreone, Antonio De Mase, Emanuele Spina, Diana Aguiar de Sousa, Mariana Almudi Souza, Alberto Fior, Miguel Serôdio, Pietro Caliandro, Aurelia Zauli, Giuseppe Reale, Ahmed Abdelalim, Sandra Mohamed Ahmed, Samah Ali Ismail, Liqun Zhang, Tara Latimer, Muhammad Elboghdany, Ahmed Elbassiouny, Tamer Roushdy, Hossam M Shokri, Federica Ferrari, Nicola Loizzo, Federico Mazzacane, Maria Guarino, Valentina Barone, Paola Forti, Giuseppe Rinaldi, Marco Rossi, Vincenzo Laterza, Giovanni Frisullo, Pier Andrea Rizzo, Aldobrando Broccolini, Marina Mannino, Valeria Terruso, Marcella Caggiula, Simona Scalise, Ana Catarina Gaspar Fonseca, Bernardo Antunes, Hrvoje Budinčević, Petra Crnac, Giovanna Viticchi, Mauro Silvestrini, Lorenzo Barba, Markus Otto, Viktoria Musienko, Piergiorgio Lochner, Benjamin Landau, Sandeep Buddha, Roumeisa Khalil, Maria Grazia Piscaglia, Ludovica Maria Miserocchi, Marialuisa Zedde, Ahmed Nasreldein, Luisa Vinciguerra, Luís Rufo Costa, Ahmed Elsayed, Mona AlBanna, Laura Tudisco, Maria Giulia Mosconi, Giovanni Merlino, Alexandros A Polymeris, Federico De Santis, Simona Sacco

Matteo Foschi: When Should We Restart Anticoagulation After a Breakthrough Ischemic Stroke?

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