Early DOAC Initiation Reduces Recurrent Stroke Risk Without Increased Bleeding in AF-Related Ischemic Stroke
A new individual patient data meta-analysis of 4 randomized trials supports early initiation of direct oral anticoagulants (DOACs) in patients with acute ischemic stroke and atrial fibrillation (AF), demonstrating a significant reduction in recurrent stroke risk without increasing hemorrhagic complications. Findings were published in The Lancet.
Researchers pooled data from 5441 participants across the TIMING, ELAN, OPTIMAS, and START trials. All patients had AF-related acute ischemic stroke and were randomized to either early (≤4 days) or later (≥5 days) DOAC initiation. The primary end point was a composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage (sICH), or unclassified stroke within 30 days. A generalized linear mixed-effects model was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), accounting for inter-trial variability.
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Among the 5,429 patients with available outcome data, the primary composite event occurred in 2.1% of the early group (n=57/2683) compared with 3.0% in the later group (n=83/2,746), translating to a significant 30% relative risk reduction (OR 0.70; 95% CI 0.50–0.98; p=0.039).
Early DOAC initiation also significantly reduced the incidence of recurrent ischemic stroke (1.7% vs. 2.6%; OR 0.66; 95% CI 0.45–0.96; p=0.029). Importantly, the rate of sICH remained low and identical in both arms (0.4%), with no evidence of increased hemorrhagic risk (OR 1.02; 95% CI 0.43–2.46; p=0.96).
“Our results suggest that clinicians should initiate DOAC treatment within 4 days and do not support the practice of delaying DOAC initiation after acute ischemic stroke with atrial fibrillation,” wrote Hakim-Moulay Dehbi, PhD, and coauthors. “Early DOAC initiation also has potential practical advantages for patient adherence and length of hospital stay.”
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