JNNP: The relationship between early and late direct oral anticoagulants after acute ischemic stroke in patients with atrial fibrillation

In patients with atrial fibrillation (AF), direct oral anticoagulants (DOAC) are at least as effective as vitamin K antagonists (VKAs) in preventing acute ischemic stroke (AIS)
.

In four key randomized controlled clinical trials, the main advantage of DOAC over VKA is the lower incidence of intracranial hemorrhage (ICH)

A recent analysis of individual patient data from seven prospective observational studies found that DOAC is better than VKA in the early stages after AIS

It is not clear how to safely start early DOAC after AIS
.

In the summary analysis of individual patient data in this prospective observational study, this article compares the 30-day recurrence of AIS, ICH, and mortality (≤ 5.

This article was published in " Journal of Neurology, Neurosurgery & Psychiatry " ( Journal of Neurology, Neurosurgery & Psychiatry )

The following patients were excluded: (1) mechanical heart valve implantation, (2) rheumatic or severe mitral stenosis, (3) oral VKA anticoagulation, (4) oral anticoagulation or oral anticoagulation started 30 days after stroke Patients with missing drug start date information
.

Early DOAC is defined as stroke ≤ 5 days, and delayed DOAC onset time is defined as> 5 days

The following patients were excluded: (1) mechanical heart valve implantation, (2) rheumatic or severe mitral stenosis, (3) oral VKA anticoagulation, (4) oral anticoagulation or oral anticoagulation started 30 days after stroke Patients with missing information on the start date of the drug

Patient research status

Patient research statusPatient research status

The study included 2550 patients
.

1362 patients (53%) received early DOAC treatment, and 1188 patients (47%) received DOAC late

In the early DOAC treatment group, 23 patients (1.

30-day results (A) recurrent AIS, (B) ICH and (C) stroke

30-day outcome (A) recurrent AIS, (B) ICH and (C) stroke 30-day outcome (A) recurrent AIS, (B) ICH and (C) stroke

The patient data cohort included 5421 patients, of which 2871 were excluded and 5 patients were excluded because ICH occurred before receiving DOAC treatment
.

The final cohort included 2550 patients

Overall, the median age was 77 years (IQR 70-84), and 1,204 patients were women (47%)

Subgroup analysis
.

Study end points included death from any cause within 30 days after the occurrence of recurrent acute ischemic stroke, intracranial hemorrhage
.

2455 cases (95.
5%) were AIS and 95 cases (4.
5%) were TIA
.
Before the onset, 773 (37%) patients received antiplatelet therapy, 497 (19%) patients received oral anticoagulant therapy, 76 patients had stroke under oral anticoagulant therapy, and anticoagulant therapy was not interrupted
.
On admission, 160 cases (6.
3%) were missing the NIHSS score, 276 cases (10.
8%) were missing renal function, and 22 cases (0.
9%) were missing information on intravenous thrombolysis
.
Recurrent AIS occurred in 37 patients (1.
5%), of which 57% occurred after DOAC treatment (21/37)
.
Six patients suffered from cerebral hemorrhage (0.
2%), and 15 patients died within the first 30 days (0.
6%)
.
The 30-day combined incidence rate of any stroke was 1.
7% (43/2550)
.

2455 cases (95.
5%) were AIS and 95 cases (4.
5%) were TIA
.
Recurrent AIS occurred in 37 patients (1.
5%), of which 57% occurred after DOAC treatment (21/37)
.
Six patients suffered from cerebral hemorrhage (0.
2%), and 15 patients died within the first 30 days (0.
6%)
.
The 30-day combined incidence rate of any stroke was 1.
7% (43/2550)
.

In short, the results of the study cannot confirm that early use of DOAC anticoagulation can increase the risk of ICH.
The risk of recurrent AIS is seven times that of ICH, and nearly half of them occurred before receiving DOAC treatment
.
This indicates that it is reasonable to receive early DOAC treatment after AIS in patients with atrial fibrillation
.

This indicates that it is reasonable to receive early DOAC treatment after AIS in patients with atrial fibrillation
.
This indicates that it is reasonable to receive early DOAC treatment after AIS in patients with atrial fibrillation
.
De Marchis  GM ,  Seiffge  DJ ,  Schaedelin  S De Marchis  GM De Marchis Seiffge  DJ Seiffge Schaedelin  S Schaedelin , et al Early versus late start of direct oral anticoagulants after acute ischaemic stroke linked to atrial fibrillation: an observational study and individual patient data pooled analysis Journal of Neurology, Neurosurgery & Psychiatry  Published Online First:  11 October 2021.
  Published Online First: doi: 10.
1136/jnnp-2021-327236 doi:Leave a message here