DOAC therapy reduces odds of symptomatic ischemic stroke compared to aspirin monotherapyDirect oral anticoagulants show lower risk of stroke than aspirin

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Published August 1, 2026 Study authors: Pertsovskaya Vera, Merkler Alexander E, Payabvash Seyedmehdi, Poli Sven, Geisler Tobias, Higuita Lin… PubMed ↗ DOI ↗ Editorial oversight: Dr. Ji-eun Park, MD · Brain, Mind & Pain

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Key Takeaway

Note that DOAC therapy reduces odds of symptomatic stroke compared to aspirin but does not affect covert brain infarction.

This meta-analysis evaluated the efficacy of direct oral anticoagulant (DOAC) therapy compared to aspirin monotherapy in patients at risk for ischemic cerebrovascular disease. The analysis included a total sample size of 3666 patients.

The primary finding was a lower odds of any ischemic cerebrovascular event, which includes both covert brain infarction and symptomatic ischemic stroke (OR, 0.65; CI, 0.50-0.85). Specifically, DOAC therapy was associated with lower odds of symptomatic ischemic stroke (OR, 0.57; CI, 0.35-0.92). However, the analysis found no significant relationship between DOAC therapy and incident covert brain infarction (OR, 0.81; CI, 0.61-1.07) or cerebral microbleeds (OR, 1.10; CI, 0.79-1.52).

The authors characterize this as a hypothesis-generating meta-analysis. Clinical application is limited by the lack of reported safety data and the exploratory nature of the findings. The results suggest that the observed reduction in overall ischemic events is primarily driven by a decrease in symptomatic stroke rather than covert infarctions.

How this fits prior evidence

This finding addresses a gap in evidence regarding DOAC efficacy compared to aspirin for preventing specific types of ischemic events. While previous coverage noted that lower aspirin doses combined with clopidogrel may reduce ischemic events in high risk patients, this meta-analysis specifically highlights the role of DOACs in reducing symptomatic stroke (OR, 0.57) without affecting covert brain infarction or cerebral microbleeds.

For people at risk of a stroke, choosing the right medication is a critical decision. A large review of data involving 3,666 patients looked at how different treatments protect the brain from ischemic events, which occur when blood flow is blocked.

The findings show that patients taking direct oral anticoagulants (DOACs) had lower odds of experiencing any ischemic cerebrovascular event compared to those taking only aspirin. Specifically, the study found a significant reduction in the odds of having a symptomatic stroke, which is a stroke that causes noticeable symptoms.

While DOACs performed better against symptomatic strokes, the data did not show a significant difference when looking at covert brain infarctions (small strokes without symptoms) or cerebral microbleeds. Because this analysis is intended to help generate new ideas for treatment, it should be viewed as one piece of the puzzle in deciding the best care path.

What this means for you:

Direct oral anticoagulants were linked to a lower risk of symptomatic stroke compared to aspirin alone.

Common questions

How does this treatment compare to aspirin?

The data shows that patients using direct oral anticoagulants had lower odds of experiencing any ischemic cerebrovascular event than those on aspirin. Specifically, the risk of a symptomatic stroke was lower for those on the anticoagulant therapy.

What is a symptomatic stroke?

A symptomatic stroke is an ischemic stroke that causes noticeable symptoms. The study found that direct oral anticoagulants led to lower odds of these specific types of strokes compared to aspirin monotherapy.

Does this treatment affect small, hidden brain issues?

The study found no significant relationship between the use of direct oral anticoagulants and covert brain infarctions (small strokes without symptoms) or cerebral microbleeds. These specific outcomes did not show a difference between treatments.

Study Details

Study typeMeta analysis

Sample sizen = 3,666

EvidenceLevel 1

PublishedAug 2026

PMID42373059

View Original Abstract ↓

BACKGROUND: Studies evaluating direct oral anticoagulant (DOAC) therapy in reducing covert brain infarction (CBI), compared to aspirin monotherapy, have generally been small and yielded inconclusive results. We, therefore, performed a systematic review and meta-analysis to summarize the effect of DOAC use with CBI and ischemic stroke. METHODS: Using PRISMA guidelines, we systematically searched PubMed, Scopus, Embase, and the Cochrane Library from inception to August 1, 2025, for randomized controlled trials or ancillary studies of trials comparing DOACs with aspirin. Studies were included if magnetic resonance imaging (MRI) scans of the brain were performed during follow-up, and rates of CBI were reported. The primary outcome was any ischemic cerebrovascular event defined as a composite of CBI or symptomatic ischemic stroke, while the secondary outcomes were symptomatic ischemic stroke, incident CBI and incident cerebral microbleeds on follow up brain MRI. After assessing study heterogeneity, we performed a meta-analysis using random-effects inverse-variance weighted models to generate log odds ratios (ORs) and evaluate the strength of association between the type of antithrombotic therapy and outcomes. A subgroup analysis was performed stratified by the type of indication for antithrombotic therapy (primary vs. secondary prevention). RESULTS: Six studies, with a total of 3,666 patients, were eligible for inclusion in the meta-analysis. DOAC use was associated with lower odds of any ischemic cerebrovascular event (OR, 0.65; CI, 0.50-0.85; I = 0.0%). In secondary analyses, DOAC use was associated with lower odds of symptomatic ischemic stroke (OR, 0.57; CI, 0.35-0.92; I = 9.7%), but there was no relationship with CBI (OR, 0.81; CI, 0.61-1.07; I = 0.0%), or cerebral microbleeds (OR, 1.10; CI, 0.79-1.52; I = 0.0%). CONCLUSIONS: In this hypothesis-generating meta-analysis of patients at risk for ischemic cerebrovascular disease, DOAC therapy, compared with aspirin, suggested a lower risk of ischemic cerebrovascular events, driven by reductions in symptomatic stroke while there was no association with covert brain infarction.

DOAC therapy reduces odds of symptomatic ischemic stroke compared to aspirin monotherapyDirect oral anticoagulants show lower risk of stroke than aspirin

How this fits prior evidence

Common questions

Study Details

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DOAC therapy reduces odds of symptomatic ischemic stroke compared to aspirin monotherapyDirect oral anticoagulants show lower risk of stroke than aspirin

How this fits prior evidence

Common questions

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Study Details

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Mirror therapy and brain stimulation improve stroke recovery outcomes

Clinical research that matters. Delivered to your inbox.

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