Adequate ≠ Protected

Even when anticoagulation is therapeutic, stroke can still occur. This one-page framework summarizes the practical approach to breakthrough ischemic stroke in atrial fibrillation, integrating evidence from ELAN, OPTIMAS, NOACISP-LONGTERM, and contemporary LAAO studies. Instead of reflexively switching DOACs, it helps clinicians classify the underlying mechanism, identify interventions that truly change outcomes, and understand where emerging therapies such as Factor XI inhibition may fit. A concise visual reference designed for everyday clinical decision-making.

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