In this episode, I’ll discuss an article about starting DOACs early vs late in ischemic stroke patients with AFib.
Patients with acute ischemic stroke are at risk of conversion to hemorrhagic stroke for a period of time after the initial event. For this reason, patients with a recent stroke were excluded from the approval trials for direct-acting oral anticoagulants like apixaban and rivaroxaban. However, when previously undiagnosed atrial fibrillation is identified as the cause of the stroke, there exists a compelling reason to start anticoagulation therapy as soon as possible. Such patients are common but they present a clinical dilemma as the tradeoff between bleeding and clotting risk is unknown.
A group of authors recently published in Circulation a randomized controlled non inferiority study looking at Early Versus Delayed Non–Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation in an attempt to resolve this dilemma.
Just under 900 patients with AFib and acute ischemic stroke were randomized within 72 hours of stroke occurrence to receiving either early DOAC therapy within 4 days of the ischemic stroke or delayed therapy starting 5 to 10 days after the stroke event.
The primary outcome was the composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or all-cause mortality at 90 days.
The primary outcome occurred in 6.9% of the early group and 8.7% of the delayed group. This met the pre-specified criteria for non-inferiority.
When the individual components of the primary outcome were examined separately, no patient in either group experienced symptomatic intracerebral hemorrhage and recurrent stroke and mortality rates were not significantly different between groups.
The authors concluded:
Early initiation was noninferior to delayed start of NOAC after acute ischemic stroke in patients with atrial fibrillation. Numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages implied that the early start of NOAC was safe and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.