Stroke prevention restructures across atrial fibrillation, lipids, and acute window
Factor XIa inhibitors entering late-stage trials, expanded thrombectomy windows, and tenecteplase displacement of alteplase are restructuring stroke prevention and acute care.
Stroke prevention and acute care are reshaping in parallel. Factor XI-pathway therapy is the next prevention frontier; asundexian (factor XIa inhibitor) failed in atrial fibrillation when OCEANIC-AF was stopped November 2023 for inferiority to apixaban but is in stroke-prevention trials (OCEANIC-STROKE), abelacimab (factor XI antibody) Phase 2 in AF showed substantial bleeding reduction versus rivaroxaban with Phase 3 LILAC-TIMI 76 reading out late 2026, and milvexian (factor XIa inhibitor) is in stroke-prevention trials. Mechanical thrombectomy windows have extended to 24 hours in selected patients with imaging-confirmed salvageable tissue. Tenecteplase is displacing alteplase as standard thrombolytic. The acute-stroke pathway is the most active it has been since the original tPA approval.
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