Patient handout

Cardioembolic Stroke (TOAST CE)

PRODUCTION

1. Your condition

This handout is for cardioembolic stroke (toast ce). Your care team identified this based on: cortical / multi-territory embolic-pattern infarct on mri dwi suggesting ce mechanism (aha/asa 2021 pmid 34024117).

Other reasons your team may use this plan: known atrial fibrillation — most common ce source (2024 esc af); mechanical or bioprosthetic valve — warfarin-mandatory ce source (2020 acc/aha vhd); lv thrombus on tte/cmr post-mi (aha/asa 2021).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
apixaban	5 mg PO BID (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL)	PO	BID	ARISTOTLE (Granger NEJM 2011 PMID 21870978) — apixaban superior to warfarin for stroke + systemic embolism with less major bleeding; 2024 ESC AF first-line; 1-3-6-12 day rule limits hemorrhagic transformation
rivaroxaban	20 mg PO daily with food (15 mg if CrCl 15-50)	PO	once daily	ROCKET-AF — alternative DOAC; 2024 ESC AF
dabigatran	150 mg PO BID (110 mg BID if bleed risk; 75 mg BID if CrCl 15-30)	PO	BID	RE-LY — alternative DOAC; idarucizumab reversal available
edoxaban	60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or P-gp inhibitor)	PO	once daily	ENGAGE AF-TIMI 48 — alternative DOAC; 2024 ESC AF

Plan: CE anticoagulation per phenotype + secondary prevention (BP / LDL / glycemic) (AHA/ASA 2021; 2024 ESC AF)

3. When to call your provider

Contact your care team if any of the following happen:

New TIA / focal deficit → ED
Recurrent stroke on therapeutic anticoag → mechanism review + LAA closure
Bleeding event on anticoag → temporary hold + reversal if life-threatening; reassess net benefit
BP >140/90 on 3-drug regimen → resistant HTN workup
LDL >55 on max statin → ezetimibe + PCSK9i
INR labile despite adherence → switch DOAC if eligible

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

AF detected on ECG / telemetry / Holter / ILR + cortical or multi-territory embolic-pattern infarct → DOAC per 1-3-6-12 day rule by NIHSS (2024 ESC AF; ARISTOTLE PMID 21870978)
LV thrombus on TTE/CMR post-MI with apical akinesis or LV aneurysm → warfarin 3-6 mo with serial imaging (AHA/ASA 2021; 2025 ACC LV thrombus consensus)
Mechanical valve (warfarin mandatory INR 2.5-3.5 mitral / 2-3 aortic; RE-ALIGN halted DOAC); native valve disease (per 2020 ACC/AHA VHD); bioprosthetic <3 mo post-op (warfarin bridge)
Mural thrombus on TTE in ischemic cardiomyopathy (EF <35% with regional wall motion abnormality) → anticoag per shared decision (AHA/ASA 2021)
Atrial myxoma or other cardiac tumor on TTE/TEE → surgical resection + perioperative anticoag bridging (AHA/ASA 2021)
Infective endocarditis with septic embolic stroke — route to cardio.infective-endocarditis.core.v1 for antimicrobial + valve surgery; defer anticoag 2-4 wk (AHA Endocarditis 2015)(life-threatening)
PFO + cryptogenic CE-pattern stroke ≤60 yo + high-risk anatomy (atrial septal aneurysm, large shunt) → percutaneous PFO closure (CLOSE Mas NEJM 2017 PMID 28902533; RESPECT)
LV aneurysm with thrombus on TTE/CMR → anticoag (warfarin 3-6 mo standard, emerging apixaban) + cardiology consult (AHA/ASA 2021)
Bioprosthetic valve replacement <3 mo prior → warfarin bridge during high-thrombosis-risk window (2020 ACC/AHA VHD; rivaroxaban RIVER trial alternative)
AF + CE stroke + absolute anticoag contraindication (recurrent major bleed, ICH on therapy) → LAA closure (Watchman per PROTECT-AF / PREVAIL)

5. Follow-up

Stroke clinic 7-14 d + 90 d + 12 mo: BP <130/80, LDL <55, HbA1c <7%, smoking cessation, anticoag adherence + HAS-BLED, AF surveillance, valve surveillance (AHA/ASA 2021)

6. Sources

Guideline: 2021 AHA/ASA Secondary Prevention + 2024 ESC AF + 2020 ACC/AHA VHD + AHA Endocarditis 2015 + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia