After Stroke in Atrial Fibrillation, Earlier Oral Anticoagulant Initiation Appears Better
A clinical trial that investigated the best time within the recommended 14-day window to initiate treatment with a direct oral anticoagulant in patients with acute ischemic stroke with atrial fibrillation found no clearly superior day, according to a study published in JAMA Neurology.
“However, the posterior probabilities suggest that initiating a direct oral anticoagulant earlier may be better than at later times within the first 2 weeks after stroke onset,” wrote corresponding author Steven J. Warach, MD, PhD, Dell Medical School, University of Texas at Austin, Austin, Texas, and study coauthors.
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The phase 2 study used a novel application of a Bayesian response-adaptive randomization strategy to determine the optimal starting time within 14 days of stroke with atrial fibrillation that would minimize the risk of ischemic and hemorrhagic events. The study included 200 patients at hospitals in Texas who had mild to moderate ischemic stroke with atrial fibrillation and were randomized to 1 of 4 groups with different direct oral anticoagulant timing. Group 1 initiated a direct oral anticoagulant for secondary stroke prevention on day 3 or 4 after stroke; group 2 initiated on day 6; group 3 on day 10; and group 4 on day 14.
The primary outcome was a composite ischemic or hemorrhagic event within 30 days from stroke onset. Researchers adjusted randomization to favor groups with higher probabilities of optimal treatment initiation.
According to the study, group 1 had no ischemic events, group 2 had 3 ischemic events, group 3 had 2 ischemic events, and group 4 had 2 ischemic events. Meanwhile, groups 1, 2, and 3 had 1 hemorrhagic event each, and group 4 had no hemorrhagic events.
The posterior probability of being the optimal timing for treatment initiation was 0.41 for group 1, compared with 0.26 for group 2, 0.17 for group 3, and 0.15 for group 4.
“An exploratory analysis demonstrated that for prevention of ischemic events by day 30, there was a posterior probability greater than 0.99 that starting use of a direct oral anticoagulant at 3 to 4 days after stroke onset was superior to starting on a later starting day,” researchers reported.
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