Early start of DOAC after ischemic stroke: Risk of intracranial hemorrhage and recurrent events.
OBJECTIVE
In patients with recent acute ischemic stroke (AIS) and atrial fibrillation, we assessed the starting time of direct, non-vitamin K antagonist oral anticoagulants (DOACs) for secondary prevention, the rate of intracranial hemorrhage (ICH), and recurrent ischemic events during follow-up.


METHODS
We included consecutive patients with nonvalvular atrial fibrillation admitted to our hospital for AIS or TIA (index event) who received secondary prophylaxis with DOAC or vitamin K antagonists (VKAs). Follow-up was at least 3 months. In the primary analysis, we compared rates of ICH and recurrent ischemic events (AIS or TIA) between patients with early (≤7 days since event; DOACearly) and those with late (>7 days, DOAClate) start of DOAC.


RESULTS
Two hundred four patients were included (median age 79 years, 89% AIS) and total follow-up time was 78.25 patient-years. One hundred fifty-five patients received DOAC with a median delay of 5 days after the index event (interquartile range 3-11) and 49 received VKA. DOAC was started early in 100 patients (65%). We observed one ICH (1.3%/y) and 6 recurrent AIS (7.7%/y). The ICH occurred in a patient taking VKA. No significant difference in the rate of recurrent AIS between DOACearly(5.1%/y) and DOAClate(9.3%/y, p = 0.53) was observed.


CONCLUSIONS
Even if DOACs are often started early after an index event, the risk of ICH appears to be low. Among all patients receiving anticoagulation, the rate of recurrent events was 6 times higher than the rate of ICH.
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland. david.seiffge@usb.ch.
David J
DJ
Seiffge
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Christopher
C
Traenka
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Alexandros
A
Polymeris
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Lisa
L
Hert
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Nils
N
Peters
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Philippe
P
Lyrer
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Stefan T
ST
Engelter
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Leo H
LH
Bonati
From the Department of Neurology and Stroke Center (D.J.S., C.T., A.P., L.H., N.P., P.L., S.T.E., L.H.B., G.M.D.M.), University Hospital of Basel; University of Basel (D.J.S.); and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland.
Gian Marco
GM
De Marchis
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D002545:Brain Ischemia / Q000150:complications; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced*; D008297:Male; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D055502:Secondary Prevention; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D014812:Vitamin K / Q000037:antagonists & inhibitors / Q000627:therapeutic use
D000925:Anticoagulants; D014812:Vitamin K