25 May 2023 • According to the results of the ELAN trial published yesterday in the New England Journal of Medicine, there doesn’t appear to be a strong reason to avoid early initiation of therapy with direct oral anticoagulants (DOACs) after an acute ischemic stroke in patients newly diagnosed with atrial fibrillation (AF).

MORE ABOUT THE ELAN TRIAL

• In the ELAN trial, conducted across 103 centers in 15 countries, investigators randomized 2,032 patients (median age 77 years; 45% women) who had an acute ischemic stroke and had AF diagnosed in the hospital to early or delayed initiation of DOAC therapy. The severity of the stroke was classified according to infarct size on imaging; 37% of participants had a minor stroke, 40% a moderate stroke, and 23% a major stroke.
• Patients with minor and moderate strokes were randomized within 48 hours. If they were assigned to early treatment, it was initiated immediately. Late treatment, on the other hand, was started on days 3 and 4 for patients with minor strokes and on days 6 and 7 for those with moderate strokes.
• Patients with major strokes were randomized on day 6. Early treatment was initiated at that point, with late treatment started on days 12 to 14.
• The rate of a primary composite outcome consisting of recurrent ischemic stroke, symptomatic intracranial hemorrhage (ICH), major extracranial bleeding, systemic embolism, or vascular death at 30 days numerically favored more-prompt treatment (2.9% vs 4.1%)

INTERPRETATION Current guidelines from the European Stroke Organization and the American Heart Association/American Stroke Association recommend delaying anticoagulation after ischemic stroke for ≥48 hours and up to 14 days depending on infarct severity and risk of hemorrhagic conversion. ELAN shortens this to ≤48 hours from stroke onset and provides further data that may support earlier initiation of DOAC therapy for nonvalvular AF after acute ischemic stroke if desired or indicated. This is based on the study findings that suggest among patients with acute ischemic stroke with concomitant nonvalvular AF who were not on therapeutic anticoagulation at the time of stroke, early versus later DOAC initiation resulted in similar rates of the composite primary outcome at 30 days.

Source: American College of Cardiology | Read full story