A systematic review and prospective individual participant data meta-analysis of randomized controlled trials supports early direct oral anticoagulants (DOACs) initiation within 4 days for patients with acute ischemic stroke and atrial fibrillation to reduce the risk of recurrent stroke without increasing bleeding risk. The analysis included four trials met inclusion criteria of 5,441 participants (mean age 77.7 years, 45.4% women, and median NIH Stroke Scale score of 5). Primary outcome (a composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or unclassified stroke within 30 days) data were available for 5,429 participants. The composite outcome occurred in 2.1% of participants who started DOACs early versus 3.0% who started later (≥5 days, OR 0.70), and early initiation was associated with a reduced risk of recurrent ischemic stroke (1.7% vs 2.6%, OR 0.66) without an increased risk of symptomatic intracerebral hemorrhage (0.4% in both groups, OR 1.02). The findings suggest that DOACs treatment should be initiated within 4 days and do not support the common practice of delaying DOACs initiation after acute ischemic stroke with atrial fibrillation due to concerns about intracerebral hemorrhage (mainly hemorrhagic transformation of the infarct) across a wide range of stroke severity. Source: https://www.thelancet.com/
