Left ventricular dysfunction after stroke: Should more patients receive anticoagulation?

Clinical takeaway: Patients with ischemic stroke and left ventricular systolic dysfunction (LVEF ≤40% or significant wall motion abnormality) should undergo thorough evaluation for LV thrombus and occult atrial fibrillation. Routine anticoagulation is not recommended for primary stroke prevention, but after ischemic stroke, anticoagulation may be reasonable on an individualized basis after weighing recurrent stroke risk against bleeding risk.

Patients with left ventricular systolic dysfunction (LVSD) without documented intracardiac thrombus remain at increased risk for first and recurrent ischemic stroke, yet evidence to support routine anticoagulation has been limited. In this new American Heart Association scientific statement, experts conclude that anticoagulation should not be routinely used for primary stroke prevention, but may provide net benefit for carefully selected patients after ischemic stroke through individualized, multidisciplinary decision-making.

The statement recommends transthoracic echocardiography (TTE) as the initial imaging test, with ultrasound-enhancing agents whenever LVEF is ≤40% or wall motion abnormalities are present to improve detection of LV thrombus. If suspicion remains despite nondiagnostic TTE, cardiac MRI (preferred) or cardiac CT should be considered. Patients at highest risk for thrombus include those with prior LV thrombus, recent myocardial infarction, LV akinesis, dyskinesis or aneurysm, or LVEF ≤40%.

Regarding antithrombotic therapy, pooled analyses continue to show no overall net benefit of anticoagulation over antiplatelet therapy for primary prevention because reductions in stroke are offset by bleeding risk. However, secondary analyses of NAVIGATE ESUS and ARCADIA suggest that direct oral anticoagulants substantially reduce recurrent stroke compared with aspirin in patients with LVSD after ischemic stroke. When anticoagulation is selected, the authors favor apixaban or rivaroxaban (using atrial fibrillation dosing) over warfarin because of greater ease of use, fewer drug interactions, and supportive clinical data. Anticoagulation timing after stroke should be individualized according to infarct size, hemorrhagic transformation, and bleeding risk.

The statement also emphasizes comprehensive management beyond antithrombotic therapy, including guideline-directed medical therapy for heart failure, prolonged cardiac rhythm monitoring to detect paroxysmal atrial fibrillation, aggressive cardiovascular risk factor modification, and coordinated care involving neurology, cardiology, pharmacy, and other specialists.

"We provide a narrative summary and meta-analysis... Whereas anticoagulation is associated with a lower risk of incident stroke in patients with LV dysfunction without thrombus, there remains no net benefit... for primary stroke prevention. For patients with stroke and LV dysfunction, anticoagulation may be associated with a lower risk of recurrent stroke and a net benefit compared with antiplatelet therapy," the authors write.

Source: Sharma R, et al. (2026 July 2) Stroke. Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus: A Scientific Statement From the American Heart Association