Factor XIa Inhibition as a Potential New Frontier in Secondary Stroke Prevention: Seemant Chaturvedi, MD

Despite meaningful advances in antithrombotic therapy over the past 2 decades, secondary stroke prevention remains an area of significant unmet need. Population aging, combined with rising rates of hypertension, diabetes, and obesity, is expected to drive up stroke incidence in the coming years, and patients continue to carry a real risk of a second event even on today’s best available therapies.¹ Clinicians have relied on the same core antiplatelet options such as aspirin, clopidogrel, and ticagrelor for years, leaving a clear opening for new mechanisms that can further reduce recurrence.

One of the most closely watched strategies is inhibition of factor XI and its activated form, factor XIa, a target that may allow clinicians to reduce thrombosis without proportionally raising bleeding risk.² This rationale was borne out in the phase 3 OCEANIC-STROKE trial (NCT05686070), which found that adding asundexian (Bayer), an oral factor XIa inhibitor, to background antiplatelet therapy reduced recurrent ischemic stroke by 26%, without a significant increase in major bleeding, among patients with recent noncardioembolic stroke or high-risk transient ischemic attack.³ Findings like these have fueled growing interest in how factor XIa inhibition could reshape the antithrombotic arsenal for secondary stroke prevention.⁴

WATCH TIME: 5 minutes | Captions are auto-generated and may contain errors.

"There’s the possibility to reduce new thrombotic events without necessarily increasing bleeding. That would be a dramatic step."

To discuss this potential new frontier, NeurologyLive^® spoke with Seemant Chaturvedi, MD, the Stewart J. Greenebaum Endowed Professor in Stroke Neurology at University of Maryland School of Medicine. In the conversation, Chaturvedi talked about why secondary stroke prevention remains an urgent unmet need despite years of progress. He also explained the biological rationale behind factor XIa inhibition and why it has generated so much enthusiasm among stroke specialists who haven’t seen a genuinely new antithrombotic mechanism reach late-stage testing in years.

From there, Chaturvedi walked through the results of OCEANIC-STROKE, one of the largest trials in this space, describing how asundexian performed on top of standard antiplatelet therapy and what the safety data showed. He closed the conversations by explaining why this is such a timely moment for the field, connecting the trial’s findings back to the aging population and growing stroke burden discussed earlier in the conversation. Watch the full video above for his complete insights.

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REFERENCES
1. Cucchiara B, Connors JM, Rabinstein AA, Sharma M. Antithrombotic therapy for noncardioembolic ischemic stroke: current evidence and future directions. Stroke. 2026;57(5):1439-1449. doi:10.1161/STROKEAHA.125.054846
2. Kidder E, Dhanesha N. Factor XIa inhibition for the prevention of thrombosis: mechanism, clinical trial signals, and indication-specific positioning. Curr Opin Hematol. Published online June 26, 2026. doi:10.1097/MOH.0000000000000941
3. Sharma M, Dong Q, Hirano T, et al. Asundexian for secondary stroke prevention. N Engl J Med. 2026;394(15):1467-1479. doi:10.1056/NEJMoa2513880
4. Ferrari F, Villa RF. Factor XI inhibition for ischemic stroke secondary prevention: pharmacology, clinical evidence, and future directions. J Clin Pharmacol. 2026;66(8):e70266. doi:10.1002/jcph.70266