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neuro.stroke-cardioembolic.v1PRODUCTION
neuro.stroke-cardioembolic.v1

Cardioembolic Stroke (TOAST CE)

neurologyacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Ischemic stroke with cardioembolic mechanism — AF, LV thrombus, valvular, mural thrombus, cardiac tumor, endocarditis, PFO, LV aneurysm, bioprosthetic <3 mo (AHA/ASA 2021; 2024 ESC AF)

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CE mechanism flagged or being investigated

Patient inputs (15)

Age affects DOAC dose (apixaban renal-criteria), PFO closure eligibility (≤60 yo per CLOSE/RESPECT), and bleed risk

Existing anticoag on board + last dose drives bridging decisions and reversal needs

Confirms ischemic territory + cortical / multi-territory embolic pattern supporting CE mechanism (AHA/ASA 2021)

ECG + continuous telemetry ≥24 h for AF detection (AHA/ASA 2021 Class I); consider 30-day MCT or ILR if cryptogenic (CRYSTAL-AF Sanna NEJM 2014 PMID 24963567)

Transthoracic echo for LV thrombus, valvular disease, wall motion (AHA/ASA 2021 Class I)

NIHSS gates DOAC start timing per 1-3-6-12 day rule: NIHSS <8 day 3, NIHSS 8-15 day 6, NIHSS ≥16 day 12 (2024 ESC AF)

eGFR for DOAC dosing (apixaban 2.5 mg BID if 2 of: age ≥80, weight ≤60, Cr ≥1.5; rivaroxaban 15 mg if CrCl 15-50; avoid DOAC if CrCl <15)

INR for warfarin dosing if mechanical valve or DOAC-contraindicated (target 2-3 for most; 2.5-3.5 mechanical mitral)

Platelets for anticoag bleed risk; cytopenia changes timing decisions

Mechanical valve mandates warfarin (DOAC contraindicated; RE-ALIGN halted); target INR 2.5-3.5 mitral, 2-3 aortic (2020 ACC/AHA VHD)

TEE for PFO, atrial appendage, valvular vegetations, aortic atheroma when TTE non-diagnostic or PFO suspected (AHA/ASA 2021)

Blood cultures × 3 if endocarditis suspected (Duke criteria; AHA Endocarditis 2015)

Recent MI with apical akinesis → LV thrombus risk → warfarin 3-6 mo (AHA/ASA 2021)

Stroke on therapeutic anticoag → reassess: subtherapeutic INR (warfarin), missed DOAC doses, additional mechanism, or LAA closure consideration (2024 ESC AF)

Troponin for MI-LV-thrombus phenotype detection (post-MI anticoag 3-6 mo for apical akinesis)

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Severity triggers (10)

10 need judgement
  • informationallife_threateninginfective_endocarditis_septic_emboli
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereafib_associated_ce
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelv_thrombus_post_mi_anticoag
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevalvular_native_or_prosthetic
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremural_thrombus_ischemic_cardiomyopathy
    Mural thrombus on TTE in ischemic cardiomyopathy (EF <35% with regional wall motion abnormality) → anticoag per shared decision (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiac_tumor_atrial_myxoma
    Atrial myxoma or other cardiac tumor on TTE/TEE → surgical resection + perioperative anticoag bridging (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparadoxical_pfo_dvt
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelv_aneurysm_thrombus
    LV aneurysm with thrombus on TTE/CMR → anticoag (warfarin 3-6 mo standard, emerging apixaban) + cardiology consult (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebioprosthetic_valve_first_3mo
    Bioprosthetic valve replacement <3 mo prior → warfarin bridge during high-thrombosis-risk window (2020 ACC/AHA VHD; rivaroxaban RIVER trial alternative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretranscatheter_laa_indication_watchman
    AF + CE stroke + absolute anticoag contraindication (recurrent major bleed, ICH on therapy) → LAA closure (Watchman per PROTECT-AF / PREVAIL)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

CE anticoagulation per phenotype + secondary prevention (BP / LDL / glycemic) (AHA/ASA 2021; 2024 ESC AF)
axis: ce_anticoagulation_and_secondary_preventionstep 1 - Step 1 — AF-associated CE: DOAC per 1-3-6-12 day rule (apixaban first-line; ARISTOTLE PMID 21870978)
Selected step "Step 1 — AF-associated CE: DOAC per 1-3-6-12 day rule (apixaban first-line; ARISTOTLE PMID 21870978)" — AF detected on telemetry / ECG / Holter / ILR + cardioembolic-pattern infarct; CHA2DS2-VASc auto-≥2 with stroke
  • apixaban
    first line
    DOAC_FXa
    5 mg PO BID (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL) • PO • BID
    triggers: af_associated_ce, nihss_lt_8_start_day3, nihss_8_15_start_day6, nihss_ge_16_start_day12
    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
    rxcui 1364430
  • rivaroxaban
    second line
    DOAC_FXa
    20 mg PO daily with food (15 mg if CrCl 15-50) • PO • once daily
    triggers: af_associated_ce, once_daily_preference
    ROCKET-AF — alternative DOAC; 2024 ESC AF
    rxcui 1114195
  • dabigatran
    second line
    DOAC_DTI
    150 mg PO BID (110 mg BID if bleed risk; 75 mg BID if CrCl 15-30) • PO • BID
    triggers: af_associated_ce
    RE-LY — alternative DOAC; idarucizumab reversal available
    rxcui 1546356
  • edoxaban
    second line
    DOAC_FXa
    60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or P-gp inhibitor) • PO • once daily
    triggers: af_associated_ce
    ENGAGE AF-TIMI 48 — alternative DOAC; 2024 ESC AF
    rxcui 1599538

outpatient playbook — drug actions (7)

  1. 1. apixaban (continue lifelong if AF)
    5 mg PO BID (renal-adjusted) • PO • BID
    trigger: AF source confirmed
    ARISTOTLE PMID 21870978; 2024 ESC AF lifelong anticoag for AF + stroke
  2. 2. warfarin (mechanical valve lifelong)
    INR 2.5-3.5 / 2-3 per valve type • PO • daily
    trigger: Mechanical valve
    2020 ACC/AHA VHD
  3. 3. warfarin discontinue if LV thrombus resolved at 3-6 mo
    Discontinue per repeat imaging • PO • N/A
    trigger: TTE/CMR thrombus resolution
    AHA/ASA 2021 + 2025 ACC LV thrombus consensus
  4. 4. aspirin 81 mg daily (post-PFO closure or post-Watchman)
    81 mg PO daily • PO • once daily
    trigger: Post-closure period complete
    Device protocol; CLOSE/PROTECT-AF
  5. 5. atorvastatin 80 mg
    80 mg PO daily • PO • once daily
    trigger: All CE patients
    2026 ACC/AHA Lipid LDL <55
  6. 6. lisinopril ± chlorthalidone ± amlodipine
    Per BP target • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN
  7. 7. varenicline / NRT / bupropion
    Per agent • PO / patch / lozenge • per agent
    trigger: Active tobacco
    AHA/ASA 2021 Class I

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cortical / multi-territory embolic-pattern infarct on MRI DWI suggesting CE mechanism (AHA/ASA 2021 PMID 34024117); Known atrial fibrillation — most common CE source (2024 ESC AF); Mechanical or bioprosthetic valve — warfarin-mandatory CE source (2020 ACC/AHA VHD).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardioembolic Stroke (TOAST CE)** (neuro.stroke-cardioembolic.v1).
Phenotype framing: CE sub-phenotype: AF-associated / LV thrombus post-MI / mechanical valve / bioprosthetic ≤3 mo / native valve / endocarditis / paradoxical PFO / LV aneurysm / cardiac tumor / cryptogenic with strong CE signal (AHA/ASA 2021; 2024 ESC AF)
Scope: Ischemic stroke with cardioembolic mechanism — AF, LV thrombus, valvular, mural thrombus, cardiac tumor, endocarditis, PFO, LV aneurysm, bioprosthetic <3 mo (AHA/ASA 2021; 2024 ESC AF)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CE anticoagulation per phenotype + secondary prevention (BP / LDL / glycemic) (AHA/ASA 2021; 2024 ESC AF)** — step "Step 1 — AF-associated CE: DOAC per 1-3-6-12 day rule (apixaban first-line; ARISTOTLE PMID 21870978)".
1. apixaban 5 mg PO BID (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL) PO BID (DOAC_FXa, first line) — 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
2. rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15-50) PO once daily (DOAC_FXa, second line) — ROCKET-AF — alternative DOAC; 2024 ESC AF
3. dabigatran 150 mg PO BID (110 mg BID if bleed risk; 75 mg BID if CrCl 15-30) PO BID (DOAC_DTI, second line) — RE-LY — alternative DOAC; idarucizumab reversal available
4. edoxaban 60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or P-gp inhibitor) PO once daily (DOAC_FXa, second line) — ENGAGE AF-TIMI 48 — alternative DOAC; 2024 ESC AF

Setting playbook (outpatient) — Stroke + cardiology clinic 7-14 d + 90 d + 12 mo: anticoag adherence + HAS-BLED, AF surveillance (MCT / ILR if cryptogenic), valve / LV-thrombus surveillance, LDL <55, BP <130/80, vascular cognitive screen (AHA/ASA 2021)
5. apixaban (continue lifelong if AF) 5 mg PO BID (renal-adjusted) PO BID — AF source confirmed (ARISTOTLE PMID 21870978; 2024 ESC AF lifelong anticoag for AF + stroke)
6. warfarin (mechanical valve lifelong) INR 2.5-3.5 / 2-3 per valve type PO daily — Mechanical valve (2020 ACC/AHA VHD)
7. warfarin discontinue if LV thrombus resolved at 3-6 mo Discontinue per repeat imaging PO N/A — TTE/CMR thrombus resolution (AHA/ASA 2021 + 2025 ACC LV thrombus consensus)
8. aspirin 81 mg daily (post-PFO closure or post-Watchman) 81 mg PO daily PO once daily — Post-closure period complete (Device protocol; CLOSE/PROTECT-AF)
9. atorvastatin 80 mg 80 mg PO daily PO once daily — All CE patients (2026 ACC/AHA Lipid LDL <55)
10. lisinopril ± chlorthalidone ± amlodipine Per BP target PO daily — BP ≥130/80 (2025 AHA/ACC HTN)
11. varenicline / NRT / bupropion Per agent PO / patch / lozenge per agent — Active tobacco (AHA/ASA 2021 Class I)

Non-pharmacologic actions:
- AHA "Get With The Guidelines" outcome documentation
- Recurrent-stroke counselling — any focal deficit = 911
- Sleep study if STOP-BANG ≥3
- Mediterranean / MIND diet + aerobic 150 min/wk
- Cardiology / EP / structural heart follow-up per phenotype
- Watchman surveillance TEE schedule if performed

AVOID / contraindication checks:
- DOAC_contraindicated_in_mechanical_valve_use_warfarin_INR_2.5 3.5_mitral_2 3_aortic (RE ALIGN halted; 2020 ACC/AHA VHD)
- DOAC_avoid_if_CrCl_<15 (renal clearance issues; ESC AF 2024)
- Apixaban_renal_dose_2.5_BID_if_2_of_3_criteria (ARISTOTLE; FDA label)
- 1 3 6 12_day_rule_for_DOAC_start_post_stroke_by_NIHSS (2024 ESC AF)
- Defer_anticoag_2 4wk_post_endocarditis_septic_emboli (AHA Endocarditis 2015)
- LAA_closure_only_if_absolute_anticoag_contraindication (PROTECT AF / PREVAIL)
- Warfarin_target_INR_2 3_for_LV_thrombus_3 6mo_with_serial_TTE (AHA/ASA 2021)
- PFO_closure_only_if_high_risk_anatomy_and_age_<=60 (CLOSE / RESPECT)

Monitoring

Regimen monitoring:
- Continuous telemetry inpatient ≥24 h for AF detection (AHA/ASA 2021 Class I)
- Outpatient 30-day MCT or ILR if cryptogenic (CRYSTAL-AF Sanna NEJM 2014 PMID 24963567)
- INR weekly until stable then q4 wk on warfarin (ACCP 2018)
- Renal function q6 mo on DOAC; q3 mo if CrCl 30-50 (2024 ESC AF)
- HAS-BLED reassessment q6 mo + after any bleed event
- TTE at 3 + 6 mo for LV thrombus resolution; CMR if TTE non-diagnostic
- Echocardiographic surveillance per valve type if bioprosthetic / mechanical valve
- Watchman device surveillance per implanter protocol (TEE at 45 d, 12 mo)

Setting (outpatient) monitoring:
- Clinic 7-14 d for medication reconciliation
- Stroke clinic 90 d + 12 mo
- INR weekly to q4 wk on warfarin (ACCP 2018)
- Renal function q6 mo on DOAC; q3 mo if CrCl 30-50
- LDL at 4-6 wk after statin then q6-12 mo
- BP home log + clinic q3 mo
- HbA1c q3 mo until controlled then q6 mo
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo

Follow-up plan: 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)
- Close-out criterion: Secondary prevention bundle on board + cardiology follow-up scheduled

Monitoring phase: Continuous telemetry inpatient; outpatient MCT or ILR if cryptogenic; INR / DOAC renal monitoring; HAS-BLED reassessment; LAA closure surveillance if performed (AHA/ASA 2021; 2024 ESC AF)

Disposition

Current setting: outpatient — Stroke + cardiology clinic 7-14 d + 90 d + 12 mo: anticoag adherence + HAS-BLED, AF surveillance (MCT / ILR if cryptogenic), valve / LV-thrombus surveillance, LDL <55, BP <130/80, vascular cognitive screen (AHA/ASA 2021)

Disposition criteria:
- Continue lifelong anticoag if AF, mechanical valve, or recurrent CE — no de-escalation without explicit risk-benefit shift (AHA/ASA 2021)
- Transition to community programs at 6-12 mo per functional status

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)
- [SEVERE] 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)
- [SEVERE] 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)

Citations

- 2021 AHA/ASA Secondary Prevention + 2024 ESC AF + 2020 ACC/AHA VHD + AHA Endocarditis 2015 + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 21870978) [PMID:21870978](https://pubmed.ncbi.nlm.nih.gov/21870978/)
- Cited evidence (PMID 24963567) [PMID:24963567](https://pubmed.ncbi.nlm.nih.gov/24963567/)
- Cited evidence (PMID 28902533) [PMID:28902533](https://pubmed.ncbi.nlm.nih.gov/28902533/)
- Cited evidence (PMID 28902537) [PMID:28902537](https://pubmed.ncbi.nlm.nih.gov/28902537/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2021 AHA/ASA Secondary Prevention + 2024 ESC AF + 2020 ACC/AHA VHD + AHA Endocarditis 2015 + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia — PMID:34024117
  • Cited evidence (PMID 21870978) — PMID:21870978
  • Cited evidence (PMID 24963567) — PMID:24963567
  • Cited evidence (PMID 28902533) — PMID:28902533
  • Cited evidence (PMID 28902537) — PMID:28902537