Failure of non-vitamin K antagonist oral anticoagulants in preventing stroke in elderly patient: a case report of multiple strokes on standard of care treatment for atrial fibrillation

Frank Bernard Ebai, Azam Mohiuddin


Atrial fibrillation (AF) is the most common type of treated heart arrhythmia. Generally, the treatment goals for atrial fibrillation are to reset the rhythm or control the rate and prevent the development and subsequent embolization of atrial thrombi. These thromboembolic events can occur with any kind of atrial fibrillation that is paroxysmal, persistent or permanent. In patients who are candidate for anticoagulation therapy, major practice guideline provides vitamin K antagonist (VKA) oral anticoagulant and non-VKA oral anticoagulants as treatment options. The risk of AF increases with age and despite treatment on standard of care anticoagulation therapy, recrudescent cardioembolic events may still arise especially in the elderly as we will see in this case.


atrial fibrillation; oral anticoagulation; stroke

Full Text:



Kato Y, Hayashi T, Tanahashi N, Kobayashi S. Cardioembolic stroke is the most serious problem in the aging society: Japan standard stroke registry study. J Stroke Cerebrovasc Dis 2015; 24(4): 811-814.

Benjamin E, Wolf P, D'Agostino R, Silbershatz H, Kannel W, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham: Heart Study. Circulation 1998; 98(10):946–952.

Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution and gender of patients with atrial fibrillation. Arch Intern Med 1995; 155(5):469–473. http://doi: 10.1001/archinte.1995.00430050045005 .

Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation 2015; 132(3):194-204.


Manno G, Novo G, Corrado E, Coppola G, Novo S. Use of direct oral anticoagulants in very elderly patients: A case report of apixaban in an ultracentenary patient. J Cardiovasc Med 2019; 20(6):403-405.

Scowcroft ACE, Lee S, Mant J. Thromboprophylaxis of elderly patients with AF in the UK: An analysis using the general practice research database (GPRD) 2000–2009. Heart 2013; 99(2):127-132.

January CT, Wann LS, Alpert JS, et al. ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society [erratum in Circulation 2014; 130(23):e270-271]. Circulation 2014; 130(23):2071-2104. http://doi:10.1161/CIR.0000000000000040.

Pengo V, Denas, Zoppellaro G, et al. Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 2018; 132(13):1365–1371.

Wada S, Toyoda K, Sato S, et al. Anti-Xa activity and event risk in patients with direct factor Xa inhibitors initiated early after stroke. Circ J 2018; 82(11):2872-2879.


Godino C, Bodega F, Melillo F, et al. Investigators Inappropriate dose of nonvitamin-K antagonist oral anticoagulants: prevalence and impact on clinical outcome in patients with nonvalvular atrial fibrillation. J Cardiovasc Med 2020; 21(10):751-758.



Copyright (c) 2021 Frank Bernard Ebai, Azam Mohiuddin

Creative Commons License
Archive of Clinical Cases is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.


ISSN: 2360-6975