For patients with mild-to-moderate strokes, early direct oral anticoagulant DOAC initiation appears safe.

The timing of initiation of oral anticoagulation after an ischaemic stroke due to atrial fibrillation needs to balance the risk for recurrent ischaemic events with the risk for haemorrhagic transformation. Few randomised trials have examined different strategies in this scenario. Now, investigators have performed a randomised trial comparing a strategy of early direct oral anticoagulant (DOAC) initiation or a later-initiation strategy. The early-initiation group started a DOAC within 48 hours after a mild or moderate stroke or on day six to seven after a severe stroke. The later-initiation group started medication on days three to four, six to seven or 12 to 14 for a mild, moderate or severe stroke. The primary study outcome was a composite of recurrent ischaemic stroke, symptomatic intracranial haemorrhage, major extracranial bleeding, systemic embolism or vascular death within 30 days of randomisation.

The study enrolled 2013 patients (median age, 78 years; 45% women) from 15 countries. Stroke severity ranged  from mild (37%), to moderate (40%), to severe (23%). The median NIH stroke scale score at the time of randomisation was three. A primary outcome event occurred in 2.9% of the early group and 4.1% of the later group. Recurrent ischaemic stroke occurred in 1.4% of the early group and 2.5% of the later group within 30 days. Symptomatic intracranial haemorrhage within 30 days was uncommon in both groups (0.2%).

Comment: This trial provides important information in that early introduction of DOACs appears to provide advantages in preventing recurrent ischaemic events. Symptomatic intracranial haemorrhage was reassuringly low in both groups. One caveat is that the neurological deficit at the time of randomisation was mild. In patients with moderate or severe neurological deficits, delayed DOAC initiation could still be reasonable.

Seemant Chaturvedi, MD, Stewart J. Greenebaum Endowed Professor of Stroke Neurology and Stroke Program Director, University of Maryland Medical System, Baltimore; Vice-Chair for Strategic Operations, Department of Neurology, University of Maryland, Baltimore, USA.

Fischer U, et al. Early versus later anticoagulation for stroke with atrial fibrillation. N Engl J Med 2023; 388: 2411-2421.

This summary is taken from the following Journal Watch titles: Neurology, Cardiology, Ambulatory Medicine, General Medicine, Hospital Medicine.