Authors:
Gian Marco De Marchis (Basel | CH)
David Seiffge (Bern | CH)
Sabine Schädeline (Basel | CH)
Duncan Wilson (London | GB)
Valeria Caso (Perugia | IT)
Monica Acciarresi (Perugia | IT)
Giorgios Tsivgoulis (Athens | GR)
Masatoshi Koga (Osaka | JP)
Sohei Yoshimura (Osaka | JP)
Kazunori Toyoda (Suita | JP)
Manuel Cappellari (Verona | IT)
Bruno Bonetti (Verona | IT)
Macha Kosmas (Erlangen | DE)
Bernd Kallmünzer (Erlangen | DE)
Philippe Lyrer (Basel | CH)
Carlo W. Cereda (Lugano | CH)
Maurizio Paciaroni (Perugia | IT)
Stefan Engelter (Basel | CH)
David J. Werring (London | GB)
Aim: We aimed to investigate recurrent ischaemic stroke (IS) and symptomatic intracranial haemorrhage (ICH) early after a recent cerebral ischaemia in patients with atrial fibrillation (AF) and their time course in relation to the initiation of direct oral anticoagulants (DOACs).
Patient & Methods: International, individual patient data meta-analysis from 8 cohort studies. We included patients with acute IS or TIA, non-valvular AF, and a DOAC within 30 days. We excluded patients with symptomatic intracranial haemorrhage (ICH) within 24 hours of endovascular recanalization therapy (n=2), or not started on a DOAC within 30 days. The endpoints were recurrent IS (re-IS) and ICH within 30 days.
Results: We included 2555 patients (median age: 77 years, IQR 70-84), of which 2460 had IS (96.5%). The median NIHSS was 5 (IQR 2-10). DOAC were started after a median of 5 days (IQR 2-10). Re-IS occurred, after a median of 6 days (IQR 2-15), in 37 patients (1.4%); 16 of these re-IS (43%) occurred prior to DOAC-start. ICH occurred, after a median of 10 days (IQR 7.5-14), in 11 patients (0.4%); 6 of these ICH (55%) occurred after DOAC-start.
Conclusions: Among patients with acute IS and AF, nearly half of the re-IS occurred prior to DOAC-start, i.e. were potentially preventable. The number of ICH potentially attributable to early start of DOAC was very low. Ongoing randomized clinical trials will show whether an earlier DOAC-start can further reduce the risk of re-IS while keeping the risk of ICH low.