Afib: direct oral anticoagulants vs vitamin-K antagonists after recent ischaemic stroke

  • Seiffge DJ & al.
  • Ann Neurol
  • 13 Apr 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • In patients with atrial fibrillation (Afib), direct oral anticoagulants (DOAC) commenced in a median of 5 days after recent cerebral ischaemia stroke is associated with a lower risk for adverse clinical outcomes compared with vitamin-K antagonists (VKA).
  • This benefit is mainly driven by decreased risk for intracranial haemorrrhage (ICH).

Why this matters

  • DOACs are often commenced earlier in clinical practice, however, not much is known about the safety and effectiveness of this approach.

Study design

  • Individual patient data analysis of 7 prospective cohort studies involving 4912 patients with Afib and a recent cerebral ischaemia and minimum follow-up of 3 months.  
  • Primary outcomes: occurrence of the composite endpoint of recurrent AIS, ICH and mortality.
  • Funding: None disclosed.

Key results

  • Of 4912 patients, 2256 (45.9%) received VKA and 2656 (54.1%) DOAC.
  • Median time from index stroke to the start of oral anticoagulation was 5 days (interquartile range [IQR], 2-12 days) with no significant difference between patients receiving VKA and DOAC (P=.53).
  • During the total follow-up of 5970 patient-years, 262 patients had AIS (4.4%/year), 71 had ICH (1.2%/year) and 439 patients died (7.4%/year).
  • DOAC vs VKA treatment was associated with lower risks for the composite endpoint (HR, 0.82; P=.05) and ICH (HR, 0.42; P<.01>
  • Risk for recurrent AIS (HR, 0.91; P=.5) and mortality (HR, 0.83; P=.09) did not significantly differ between DOAC and VKA treatment.

Limitations

  • Observational, non-randomised study
  • Choices of anticoagulation were influenced by unmeasurable factors associated with individual physician’s decision.

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