Off-Label Use of New Oral Anticoagulants

More than 40 years ago, the rudimentary train of secondary stroke prevention reached a milestone station: the demonstration in several randomized controlled trials that oral vitamin K antagonists reduce the risk of recurrent ischemic event in patients with stroke and nonvalvular atrial fibrillation (AF). Warfarin rapidly became an evidence-based standard of care. This stroke prevention paradigm was then easily translated, and blessed by the church of the eminence-based medicine, into recommendations for adding other non-AF cardioembolic wagons in the train of oral anticoagulation (OAC). Recently, large randomized controlled trials have shown that new oral anticoagulants (NOACs) are an alternative for vitamin K antagonists to prevent stroke in patients with AF. This novel milestone led not only to a rapid implementation of NOACs in AF population but also encouraged its off-label use in several non-AF cardioembolic strokes where OAC is indicated. However, given the complexity of contemporary evidence-based stroke care, the off-label use of NOACs represents heavy wagons that may derail the train of stroke prevention in the uncertainty station.Drs Choi and Hill like long trains. They consider that given the safety benefit of NOACs in AF trials, it would be reasonable to translate and apply the favorable NOACs profile to our patient with low ventricular ejection fraction and sinus rhythm. Conversely, …