Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.
R, L., U, P., JR, S., CA, P., LA, S., TS, F., & AM, D. (2026). Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.. BMJ (Clinical research ed.). https://doi.org/10.1136/bmj-2025-084905
R L, U P, JR S, CA P, LA S, TS F, et al. Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.. BMJ (Clinical research ed.). 2026; doi: 10.1136/bmj-2025-084905
R L, U P, JR S, et al. Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.[J]. BMJ (Clinical research ed.). 2026. DOI: 10.1136/bmj-2025-084905.
@article{r2026,
author = {Lun R and Pensato U and Shaw JR and Pivato CA and Sposato LA and Field TS and Demchuk AM},
title = {Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.},
journal = {BMJ (Clinical research ed.)},
year = {2026},
doi = {10.1136/bmj-2025-084905},
note = {PMID: 42508832},
}
TY - JOUR AU - Lun R AU - Pensato U AU - Shaw JR AU - Pivato CA AU - Sposato LA AU - Field TS AU - Demchuk AM TI - Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation. T2 - BMJ (Clinical research ed.) PY - 2026 DO - 10.1136/bmj-2025-084905 AN - PMID:42508832 ER -
Ischemic stroke is a serious complication of atrial fibrillation that is associated with substantial morbidity and mortality. For patients with non-valvular atrial fibrillation, treatment with a direct oral anticoagulant (DOAC) is first line treatment for stroke prevention. Ischemic strokes can still occur, however, despite appropriate anticoagulation-an event known as a breakthrough stroke. In this review, we provide an examination of breakthrough stroke through its epidemiology, mechanisms by which breakthrough strokes happen, and a framework for classification. We then propose a systematic, stepwise algorithm to investigate breakthrough stroke, including standardized criteria to identify an ideal population for future clinical trials using the AF-BREACH criteria (Atrial Fibrillation related BReakthrough Embolic Stroke despite appropriate anticoagulation without alternative Cause identified). Lastly, we discuss the emerging evidence for pharmacological and non-pharmacological management strategies.