Anticoagulation in Patients With Stroke With Infective Endocarditis

Stroke complicating infective endocarditis (IE) poses a therapeutic dilemma, particularly in patients with prosthetic valves (PV). Most experts recommend against the use of anticoagulation because of increased risk of intracerebral hemorrhage (ICH). Some worry that stopping anticoagulation increases the risk of clot formation on the PV and further embolization. Brain embolization in the setting of IE may result in a wide spectrum of clinical scenarios with different risk/benefit profiles to anticoagulation. Dr Rasmussen, a cardiologist, states that the potential harmful effect of anticoagulation is overestimated and that the beneficial effect of ongoing anticoagulation to prevent early recurrent stroke counterbalances the low risk of ICH. He, therefore, recommends in our case switching from warfarin to heparin due to the likelihood of urgent surgery. Conversely, Dr Sila, a neurologist, argues that anticoagulation should not be initiated and patients already on anticoagulantion should have it stopped as soon as a diagnosis of IE is suspected given the low rate of early recurrent stroke and high incidence of early ICH and hemorrhagic transformation (HT) in patients with stroke with Staphylococcus aureus IE. …