In this episode, I’ll discuss early as compared with later initiation of direct oral anticoagulants (DOACs) in patients with atrial fibrillation who have had an acute ischemic stroke.
How soon to start anticoagulation after stroke due to afib is a matter of significant debate as there is a concern for both hemorrhagic complications from starting too soon and stroke recurrence from starting too late.
Authors recently published in New England Journal of Medicine an open label multi center trial looking at early vs later anticoagulation in patients with afib who had an ischemic stroke.
Early anticoagulation was defined as within 48 hours after a minor or moderate stroke or on day 6 or 7 after a major stroke and later anticoagulation was defined as 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.
Just over 2000 patients were split between groups.
The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days after randomization.
The authors found that:
In this trial, the incidence of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death at 30 days was estimated to range from 2.8 percentage points lower to 0.5 percentage points higher (based on the 95% confidence interval) with early than with later use of DOACs.
While this finding seems to be phrased in a way to suggest favoring early anticoagulation, the results indicate no difference between early and late anticoagulation in terms of the composite outcome. Therefore if anticoagulation is desired to start as early as within 48 hours of a minor or moderate stroke or 6 days after a major stroke in a patient with nonvalvular afib, this trial gives support to such a decision.
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