Log in to MyACC
Early Initiation of DOACs After Stroke in Nonvalvular AF
Study Questions:
In ischemic stroke patients with nonvalvular atrial fibrillation (NVAF), how does early initiation of direct oral anticoagulants (DOACs) post-stroke compare to later initiation of DOACs post-stroke in terms of efficacy and safety?
Methods:
This is an observational, registry-based study of acute ischemic stroke/transient ischemic attack patients with NVAF treated at one of 18 participating stroke centers in Japan. Patients were included in the analysis if they were started on a DOAC during their index stroke hospitalization. The choice of DOAC and timing of DOAC initiation was determined by the local investigator in charge. The primary efficacy outcome was stroke or systemic embolism at 2 years post-stroke, and the primary safety outcome was major bleeding at 2 years post-stroke.
Results:
A total of 499 patients were included in the analysis. Median age was 75 (interquartile range, 69-82) years. The median duration between stroke onset and DOAC administration was 4 days. The early group consisted of 223 patients who were started on DOACs within 3 days of stroke onset. The later group consisted of 276 patients who were started on DOACs at 4 days or later. Patients in the early group had lower baseline National Institutes of Health Stroke Scale scores (median of 3 compared to 5) and smaller infarcts than the later group. No differences in the primary efficacy outcome or primary safety outcome were observed between the two groups.
Conclusions:
When investigators are allowed to choose when to start a DOAC after ischemic stroke in NVAF patients, there is no difference in efficacy or safety between early compared to later initiation of anticoagulation.
Perspective:
When to restart anticoagulation after ischemic stroke is a frequently encountered question in inpatient neurology. The risk of hemorrhagic transformation must be weighed against the risk of recurrent cardioembolic stroke. Size of infarct is a key factor in deciding when to start or restart anticoagulation after ischemic stroke because hemorrhagic transformation is more likely with larger strokes. Because of the observational nature of this study, its results will be unlikely to lead to a change in clinical practice. Providers will likely continue to recommend early anticoagulation for patients with smaller infarcts and later initiation for patients with larger infarcts, just as the local investigators did in this study.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Embolism, Geriatrics, Hemorrhage, Infarction, Inpatients, Ischemic Attack, Transient, Neurology, Secondary Prevention, Stroke, Vascular Diseases
< Back to Listings
