Lancet

Early anticoagulation initiation is best for afib patients with acute ischemic stroke

July 21, 2025

DOAC initiation within 4 days of acute ischemic stroke in afib patients reduced risks for the composite outcome of ischemic stroke recurrence, symptomatic intracerebral hemorrhage, or unclassified stroke within 30 days, according to this systematic review and meta-analysis. Benefits were seen consistently across subgroups (e.g., based on stroke severity, reperfusion treatment, previous oral anticoagulant use).

Study Details. This systematic review and individual patient data meta-analysis (N = 5,441 afib patients with ischemic stroke; mean age, 77.7 years; women, 45%, median NIH Stroke Scale, 5) included four eligible trials: ELAN, OPTIMAS, START, and TIMING. Primary outcome: composite of ischemic stroke recurrent, symptomatic intracerebral hemorrhage, or unclassified stroke, within 30 days of being randomized.

Results. The primary outcome was detected in 2% of patients who started DOAC early (≤4 days) vs. 3% of those who started later (≥5 days) (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.50–0.98; p = 0.039). Specifically, early DOAC treatment reduced recurrent ischemic stroke risk: 1.7% vs. 2.6% with later start (OR, 0.66; 95% CI, 0.45–0.96; p = 0.029). Early DOAC initiation wasn’t associated with increased symptomatic intracerebral hemorrhage risk.

Source:

Dehbi HM, et al. (2025, July 5). Lancet. Collaboration on the optimal timing of anticoagulation after ischaemic stroke and atrial fibrillation: a systematic review and prospective individual participant data meta-analysis of randomised controlled trials (CATALYST). https://pubmed.ncbi.nlm.nih.gov/40570866/