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Stroke Despite Anticoagulation — RACP Adult Medicine MCQ

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HardNeurologyStroke Despite AnticoagulationRACP Adult Medicine

A 72-year-old with atrial fibrillation has an ischaemic stroke while prescribed full-dose rivaroxaban. Pharmacy records and interview support adherence, but the acute work-up is incomplete. What should occur before empirically changing anticoagulants?

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Correct answer: D — Confirm dose, renal function and interactions, then investigate competing stroke mechanisms and intracardiac thrombus

The best answer is “Confirm dose, renal function and interactions, then investigate competing stroke mechanisms and intracardiac thrombus”. A stroke during anticoagulation can reflect dosing, absorption, interactions, nonadherence, left-atrial thrombus or a competing mechanism such as large-artery disease. These are investigated before an unproven switch. Routine addition of aspirin increases bleeding unless a separate indication exists; supratherapeutic dosing and a nonstandard INR target are unsafe, while stopping anticoagulation leaves ongoing AF-related risk untreated.

Reference: Stroke Foundation: Living clinical guidelines for stroke management: https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management