Across a range of stroke severity, early initiation of direct oral anticoagulants was safe in patients with recent stroke and atrial fibrillation.

Current guidelines recommend delaying anticoagulation for 12 to 14 days in patients with atrial fibrillation and a major stroke because of concern about haemorrhagic transformation. However, clinical trial data were lacking until recent studies, including the ELAN trial, which showed numerically fewer primary endpoint events (recurrent ischaemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial bleeding or vascular death) at 30 days with early anticoagulation. In this post hoc analysis of ELAN, researchers examined whether stroke severity affected outcomes. They categorised strokes as minor (less than 1.5 cm in diameter), moderate (more than 1.5 cm but less than the entire territory of the anterior cerebral artery [ACA] or middle cerebral artery [MCA]) or major (entire ACA or MCA territory or more than 1.5 cm in the posterior circulation). The early group received direct oral anticoagulant (DOAC) therapy within 48 hours for minor or moderate stroke and within six to seven days for major stroke. The late group received DOAC therapy within three to four days after minor stroke, six to seven days after moderate stroke, and 12 to 14 days after major stroke.

In 1962 patients (median age, 77 years; 46% women) with data available, the NIH Stroke Scale score before randomisation was two for minor stroke, three for moderate stroke, and eight for major stroke. Comparing early versus late treatment, the primary endpoint occurred in 2.7% versus 3.0% of patients with minor stroke, 2.8% versus 3.6% with moderate stroke and 3.7% versus 7.0% with major stroke. Stroke severity did not affect the primary endpoint results. No symptomatic haemorrhages occurred in the 225 patients with major stroke who received early DOAC therapy.

Comment: After the initial ELAN study’s publication, there was a shift in the field toward early DOAC therapy. These reassuring data demonstrate that this change in practice to early DOAC therapy is safe for patients with a range of stroke sizes. One caveat is that participants’ NIH Stroke Scale scores were relatively low, so results cannot be extrapolated to patients with severe neurological deficits.

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.

Goeldlin MB, et al. Early vs late anticoagulation in minor, moderate, and major ischemic stroke with atrial fibrillation: post hoc analysis of the ELAN randomized clinical trial. JAMA Neurol 2024; 81: 693-702.

This summary is taken from the following Journal Watch title: Neurology.