Prof Jess Dawson in new Publication
Published: 25 May 2023
Early versus Later Anticoagulation for Stroke with Atrial Fibrillation
Early versus Later Anticoagulation for Stroke with Atrial Fibrillation
Urs Fischer, M.D., Masatoshi Koga, M.D., Ph.D., Daniel Strbian, Ph.D., +Mattia Branca, Ph.D., Stefanie Abend, B.Sc., Sven Trelle, M.D., Maurizio Paciaroni, M.D., Götz Thomalla, M.D., Patrik Michel, M.D., Krassen Nedeltchev, M.D., Leo H. Bonati, M.D., George Ntaios, M.D., Thomas Gattringer, Ph.D., Else-Charlotte Sandset, Ph.D., Peter Kelly, M.D., Robin Lemmens, Ph.D., P.N. Sylaja, M.D., Diana Aguiar de Sousa, Ph.D., Natan M. Bornstein, M.D., Zuzana Gdovinova, M.D., Ph.D., Takeshi Yoshimoto, M.D., Ph.D., Marjaana Tiainen, M.D., Ph.D., Helen Thomas, R.N., Manju Krishnan, M.B., B.S., Gek C. Shim, M.B., B.Ch., Christoph Gumbinger, M.D., Jochen Vehoff, M.D., Liqun Zhang, M.D., Ph.D., Kosuke Matsuzono, M.D., Ph.D., Espen Kristoffersen, M.D., Ph.D., Philippe Desfontaines, M.D., Peter Vanacker, M.D., Ph.D., Angelika Alonso, M.D., Yusuke Yakushiji, M.D., Ph.D., Caterina Kulyk, M.D., Dimitri Hemelsoet, M.D., Sven Poli, M.D., Ana Paiva Nunes, M.D., Nicoletta Caracciolo, M.D., Peter Slade, M.B., B.Ch., Jelle Demeestere, M.D., Ph.D., Alexander Salerno, M.D., Markus Kneihsl, M.D., Ph.D., Timo Kahles, M.D., Daria Giudici, M.D., Kanta Tanaka, M.D., Ph.D., Silja Räty, M.D., Ph.D., Rea Hidalgo, R.N., David J. Werring, F.R.C.P., Ph.D., Martina Göldlin, M.D., Marcel Arnold, M.D., Cecilia Ferrari, M.B.A.-I.H.M., Seraina Beyeler, Ph.D., Christian Fung, M.D., Bruno J. Weder, M.D., Turgut Tatlisumak, M.D., Ph.D., Sabine Fenzl, M.D., Beata Rezny-Kasprzak, M.D., Arsany Hakim, M.D., Georgia Salanti, Ph.D., Claudio Bassetti, M.D., Jan Gralla, M.D., David J. Seiffge, M.D., Thomas Horvath, M.D., and Jesse Dawson, M.D. for the ELAN Investigator
Introduction
A nticoagulation with direct oral anticoagulants (DOACs) reduces the risk of ischemic stroke and systemic embolism among persons with atrial fibrillation. However, whether the timing of DOAC initiation influences the risks of stroke recurrence and bleeding after an acute ischemic stroke is unclear. Early initiation may increase the risk of intracranial hemorrhage, whereas later initiation may increase the risk of early stroke recurrence.
The risk of both recurrent ischemic stroke and intracranial hemorrhage is highest in the first few days after acute ischemic stroke, and although studies and small randomized trials suggest that early use of DOACs may be safe, these investigations have had selection bias or small sample sizes. Given the lack of high-quality evidence, guideline recommendations regarding the timing of initiation of anticoagulation have varied. Some recommendations suggest initiation of anticoagulation at 1, 3, 6, or 12 days after a transient ischemic attack or after a minor, moderate, or severe ischemic stroke, respectively (the “1-3-6-12–day rule”). This guidance, which has been based on the observation that the risk of hemorrhagic transformation is related to infarct size, is followed in many countries. A neuroimaging-based risk-stratification approach may help to minimize the risk of intracranial hemorrhage.
We conducted the Early versus Late Initiation of Direct Oral Anticoagulants in Post-ischemic Stroke Patients with Atrial Fibrillation (ELAN) randomized trial, which aimed to estimate the safety and efficacy of early initiation of DOACs as compared with later, guideline-based initiation, using imaging-based selection criteria in persons who have had a recent stroke and have atrial fibrillation.
First published: 25 May 2023