Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk.

Journal Article (Journal Article;Multicenter Study)

OBJECTIVE: Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high-risk features on echocardiography. METHODS: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. RESULTS: Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0-3 days: 10.3%, 64/617; 4-14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0-3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50-4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36-1.62, p = 0.482). INTERPRETATION: In this multicenter real-world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. ANN NEUROL 2020;88:807-816.

Full Text

Duke Authors

Cited Authors

  • Yaghi, S; Trivedi, T; Henninger, N; Giles, J; Liu, A; Nagy, M; Kaushal, A; Azher, I; Mac Grory, B; Fakhri, H; Brown Espaillat, K; Asad, SD; Pasupuleti, H; Martin, H; Tan, J; Veerasamy, M; Liberman, AL; Esenwa, C; Cheng, N; Moncrieffe, K; Moeini-Naghani, I; Siddu, M; Scher, E; Leon Guerrero, CR; Khan, M; Nouh, A; Mistry, E; Keyrouz, S; Furie, K

Published Date

  • October 2020

Published In

Volume / Issue

  • 88 / 4

Start / End Page

  • 807 - 816

PubMed ID

  • 32656768

Pubmed Central ID

  • PMC8259451

Electronic International Standard Serial Number (EISSN)

  • 1531-8249

Digital Object Identifier (DOI)

  • 10.1002/ana.25844


  • eng

Conference Location

  • United States