The Lead Episode 19: A Discussion of Early versus Later Anticoagulation for Stroke with Atrial Fibrillation-The New England Journal of Medicine

The New England Journal of Medicine

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The effect of early initiation of direct oral anticoagulants (DOACs) compared to later initiation in individuals with atrial fibrillation and acute ischemic stroke is uncertain. To investigate this, researchers conducted an open-label trial at multiple sites in 15 countries. Participants were randomly assigned to receive early anticoagulation (within 48 hours or on day 6 or 7 after a stroke) or later anticoagulation (on day 3 or 4 after a minor stroke, day 6 or 7 after a moderate stroke, or day 12, 13, or 14 after a major stroke). The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days. Secondary outcomes were assessed at 30 and 90 days. Of the 2013 participants, 2.9% in the early-treatment group and 4.1% in the later-treatment group experienced a primary-outcome event within 30 days. Recurrent ischemic stroke occurred in 1.4% of the early-treatment group and 2.5% of the later-treatment group within 30 days. Symptomatic intracranial hemorrhage occurred in 0.2% of both groups within 30 days. The results suggest that the incidence of the primary outcome did not significantly differ between the two groups within 30 days, with a possible reduction in risk associated with early initiation. Further research is needed to determine the optimal timing of anticoagulation initiation after stroke.

Keywords

direct oral anticoagulants

atrial fibrillation

acute ischemic stroke

early initiation

later initiation

open-label trial

anticoagulation

recurrent ischemic stroke

symptomatic intracranial hemorrhage

optimal timing