Dave,MD

Health and Wealth

[sikandar adwani @SikandarAdwani]

A patient with atrial fibrillation is taking apixaban regularly.

No missed doses.

Correct dose.

Yet he develops an ischemic stroke.

Our first reaction is often:

The DOAC has failed.

Not so fast.

The first question is NOT

Which anticoagulant should I switch to?

The first question is

Why did the stroke happen despite anticoagulation?

That single change in thinking can completely change management.

I now use a simple bedside approach.

DOAC BREAKTHROUGH STROKE CHECKLIST

1️⃣ Was the patient really taking the DOAC?
• Missed doses
• Stopped before a procedure
• Couldn't obtain the medicine

2️⃣ Was the dose actually correct?
Many elderly patients receive reduced-dose DOACs without fulfilling guideline criteria.

Underdosing can become undertreatment.
3️⃣ Any hidden drug interaction?
Think especially of enzyme-inducing antiseizure drugs.

Carbamazepine.
Phenytoin.
Phenobarbital.
Primidone.
These can significantly reduce DOAC levels.

4️⃣ Any absorption problem?
One practical pearl many people miss:

Rivaroxaban 15 mg and 20 mg should be taken with food.
Also ask about bariatric surgery or inflammatory bowel disease.

5️⃣ Was AF really the cause?
Not every stroke in an AF patient comes from AF.
Always look for:
• Carotid stenosis
• Intracranial atherosclerosis
• Carotid web
• Dissection
• Small vessel disease

6️⃣ Is there another prothrombotic state?
Think of:
• Occult malignancy
• Antiphospholipid syndrome
• Left atrial appendage thrombus
Only after excluding all of these should we call it a true breakthrough stroke.

The biggest practical message from the 2026 BMJ review?

There is no good evidence that routinely switching from one DOAC to another reduces recurrent stroke.

There is also no evidence to routinely add aspirin, but there is clear evidence that it increases bleeding risk.

The answer is usually not a new drug.

The answer is finding the missed mechanism.

In stroke medicine, changing the prescription is easy.
Finding the real reason the patient stroked is what changes outcomes.

#NeuroX #MedX #Anticoagulation #AF

Reference
Lun R, et al.
Investigation and management of breakthrough ischemic stroke in anticoagulated patients with atrial fibrillation.
BMJ. 2026;394:e084905.

[Paolo Tarantino @PTarantinoMD]

Whenever I see presentation slides fully designed by AI, a switch turns off in my brain. My attention suddenly drops.

The content may be ok. But realizing that they are AI-generated, and not knowing how much human input/review is included, makes me less engaged.

Is it just me?

[Family Feud @FamilyFeud]

4 things on your sheets after breakfast in bed. 🛌😳🍳 Annette’s answer makes Steve Harvey jelly!

[MDM @Eng_Katumba]

This British tourist shared a unique experience of when he lived in some African countries. On the other hand, when you listen to the stories of Africans living in the west, you can't fail to wonder 🤔🤔🤔

[Anjeyo E. Ananda @anj_116_]

Chaotic Grandma.

"Eshirotsa, emihuni chia rulao" 😂😂😂😂😂😂😂😂

[Dave,MD @wafdave]

@chiamakaafc Anelka

[Mohammed Hersi : Mr Optimist @mohammedhersi]

What a talent.

Hats off to this guy...amazing at the same time the message is a sad one.

Please us follow his Tik Tok channel and support him......https://t.co/PHZxj4ahIT

[Sheryllisa @Sheryllisa52263]

Sifuna advert 🔥 #SisiNdioSifuna @LindaMwananchi_

[Dave,MD @wafdave]

City beggars in Nairobi

[Omwamba 🇰🇪 @omwambaKE]

Ever wondered why men have kids that don't look like them; here maybe a reason why.
Video courtesy ~ Dr. King'ori

[Context Pin It (P) @pinitreply]

She had no idea she was talking to the CEO 😱

[Dave,MD @wafdave]

😂

[Dave,MD @wafdave]

@kamohelo_m39094 @FabrizioRomano 10 African countries. Add France

[Mwaks @Realmwaks]

Men after being single in 2 weeks.

[Abraham Okah(info hub) @AbrahamOkah2]

Your legs shall touch the countries your parents only saw on TV. That is a prophecy. Amen!

[MedNorms @MedNorms]

Residency is three legged
Academics
Clinical Practice
Research

Now depending on your centre … you can be balanced on all three legs or be limping 😂😂

[Reads with Ravi @readswithravi]

There’s a Japanese saying that I love:

“Your garden is not complete until there is nothing else you can take out of it.”

[Dave,MD @wafdave]

#MedicalHumor #MedTwitter  #ResidentLife #MedMemes #DoctorHumor  #Surgery #Radiology #ID #Anaesthesia

[aurelie @emangiyato]

face filters gone wrong 🤣🤣

[Dave,MD @wafdave]

@gacikiraMD Get in touch with any medical student or residents in UON and MU. They have free access courtesy of their institutions. I can help you get an account if you're interested.