Anticoagulation earns its place at CHA2DS2-VASc 1, and cholinesterase inhibitors stop being off-limits in Lewy body dementia

The edition in brief

SINGLE-AF randomised 1,803 South Korean patients with atrial fibrillation at intermediate stroke risk - CHA2DS2-VASc 1 in men, 2 in women - to a direct oral anticoagulant or none. At 24 months the composite of stroke, systemic embolism, major bleeding or cardiovascular death occurred in 0.5% on a DOAC and 1.5% without (difference -1.0 percentage points, 95% CI -2.0 to -0.1; HR 0.31, 0.10-0.94). Stroke occurred in 3 versus 10 patients. Major bleeding looked similar between groups. The event counts are very small and the trial was open-label in a young cohort (mean age 60.4), so this supports rather than settles the class IIa recommendation. A Lancet Neurology review sets out the case for treating dementia with Lewy bodies with cholinesterase inhibitors even when cardiac conduction abnormalities are present. Bradycardia is common in this population because of autonomic degeneration, and the drugs are frequently withheld on that basis. Randomised and meta-analytic evidence supports a favourable cardiac safety profile, and the authors argue for screening and monitoring rather than avoidance. A Brain review examines the 2024 McDonald criteria as an intervention in clinical behaviour. Widening the routes to diagnosis - the optic nerve, the central vein sign, paramagnetic rim lesions - raises misdiagnosis risk wherever imaging quality and subspecialist interpretation are variable, which is most places. The paper proposes safeguards and tighter biomarker definitions. A Neurology commentary on CREST-2 argues carotid stenting is now an evidence-based adjunct to intensive medical management in high-grade asymptomatic stenosis, conditional on patient selection, operator skill and shared decision-making.