Patients with acute ischemic stroke related to atrial fibrillation (a-fib) are at a high risk of recurrent stroke and intracranial hemorrhage. This study compared the efficacy and safety of a non-vitamin K antagonist oral anticoagulant (NOAC), rivaroxaban, with dose adjusted warfarin among patients with mild a-fib related, acute, ischemic stroke.

Subjects were patients with acute ischemic stroke and nonvalvular a-fib. The subjects were randomized to receive rivaroxaban or warfarin, adjusted to an international normalized ratio (INR) of 2-3. The rivaroxaban group received rivaroxaban, 10 mg once daily for the first five days, followed by 20 mg daily. The warfarin group was titrated to an INR of 2-3. At week four, an MRI was performed to assess for new ischemic lesions and new intracranial hemorrhage.

Data from 183 patients were included in the analysis. The primary endpoint occurred in 49.5% of the rivaroxaban group and in 54.5% of the warfarin group (P＝0.45). A new ischemic stroke was seen in 29.5% of the rivaroxaban group and 35.6% in the warfarin group (P＝0.38). A new intracranial hemorrhage was seen in 31.6% of the rivaroxaban group and in 28.7% of the warfarin group (P＝0.68). While not statistically significant, parenchymal hematoma with mass effect was observed more frequently in the warfarin group, while type I hemorrhagic infarction was more frequent in the rivaroxaban group.

This study of patients with atrial fibrillation related ischemic strokes found that rivaroxaban and warfarin, initiated within five days of stroke, are safe and effective for preventing early clinical stroke recurrence.