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Early start of DOAC after ischemic stroke: Risk of intracranial hemorrhage and recurrent events

David J Seiffge, Christopher Traenka, Alexandros Polymeris, Lisa Hert, Nils Peters, Philippe Lyrer, Stefan T Engelter, Leo H Bonati, Gian Marco De Marchis
Neurology 2016 November 1, 87 (18): 1856-1862

OBJECTIVE: In patients with recent acute ischemic stroke (AIS) and atrial fibrillation, we assessed the starting time of direct, non-vitamin K antagonist oral anticoagulants (DOACs) for secondary prevention, the rate of intracranial hemorrhage (ICH), and recurrent ischemic events during follow-up.

METHODS: We included consecutive patients with nonvalvular atrial fibrillation admitted to our hospital for AIS or TIA (index event) who received secondary prophylaxis with DOAC or vitamin K antagonists (VKAs). Follow-up was at least 3 months. In the primary analysis, we compared rates of ICH and recurrent ischemic events (AIS or TIA) between patients with early (≤7 days since event; DOACearly ) and those with late (>7 days, DOAClate ) start of DOAC.

RESULTS: Two hundred four patients were included (median age 79 years, 89% AIS) and total follow-up time was 78.25 patient-years. One hundred fifty-five patients received DOAC with a median delay of 5 days after the index event (interquartile range 3-11) and 49 received VKA. DOAC was started early in 100 patients (65%). We observed one ICH (1.3%/y) and 6 recurrent AIS (7.7%/y). The ICH occurred in a patient taking VKA. No significant difference in the rate of recurrent AIS between DOACearly (5.1%/y) and DOAClate (9.3%/y, p = 0.53) was observed.

CONCLUSIONS: Even if DOACs are often started early after an index event, the risk of ICH appears to be low. Among all patients receiving anticoagulation, the rate of recurrent events was 6 times higher than the rate of ICH.


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Warwick Rivlin wrote:


Have the results been stratified to either an NIHS score or radiological volume of infarction?
As I understand it, the largest risk of haemorrhagic transformation is the size of the infarction (followed by hypertension following stroke).

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