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Bern/Vienna – Evidence is mounting for the benefit of early administration of direct oral anticoagulants (DOACs) after an ischemic stroke. However, the study situation is not yet clear – and there are also counterarguments. This is shown by two recently published studies on the subject.

A working group from Bern analyzed data from the ELAN study (“Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation”). They recorded the results of an early versus a late start to treatment with DOACs in patients with ischemic stroke with and without so-called hemorrhagic transformation. The hemorrhagic transformation was divided into “hemorrhagic infarction” and “parenchymal bleeding”.

“Early initiation of direct oral anticoagulation earlier than 48 hours after ischemic stroke in mild and moderate strokes and 6 to 7 days in severe strokes does not increase the rate of symptomatic intracranial bleeding in patients with hemorrhagic transformation and may be beneficial in patients with type 1 and 2 hemorrhagic infarctions,” the researchers report in the journal Circulation (2024, DOI: 10.1161/CIRCULATIONAHA.124.069324).

However, in patients with parenchymal bleeding, early anticoagulation may worsen functional outcomes, according to the analysis, but this needs to be confirmed by data from ongoing studies, say the Swiss scientists.

“A 25% deterioration in functional outcome is clinically very relevant and gives cause for concern in patients with hemorrhagic transformation,” commented Gerhard Hamann and Dirk Sander to the German Medical Journal (DÄHamann and Sander are coordinators of the guideline “Secondary prevention of ischemic stroke and transient ischemic attack” of the German Stroke Society (DSG) and the German Society of Neurology (DGN).

In a study published in the journal JAMA Neurology (2024, DOI: 10.1001/jamaneurol.2024.1450) – also by a Swiss group – the probability of the study endpoint in participants with mild, moderate and severe stroke was similar with early versus late DOAC use.

Endpoints included recurrent ischemic stroke, symptomatic intracranial hemorrhage, extracranial hemorrhage, systemic embolism, or vascular death within 30 days.

“This means that early DOAC treatment was not associated with a higher rate of bleeding complications, particularly symptomatic intracranial bleeding, or other adverse events regardless of infarct size, including major strokes,” the group concludes.

“There is not yet sufficient data to support a complete, strong recommendation for earlier oral anticoagulation,” is the conclusion of guideline coordinators Hamann and Sander. © hil/aerzteblatt.de