Early versus late anticoagulation for ischaemic stroke associated with atrial fibrillation: multicentre cohort study. Issue 3 (19th November 2018)

• Record Type: Journal Article
• Authors: Wilson, Duncan; Ambler, Gareth; Banerjee, Gargi; Shakeshaft, Clare; Cohen, Hannah; Yousry, Tarek A; Al-Shahi Salman, Rustam; Lip, Gregory Y H; Houlden, Henry; Brown, Martin M; Muir, Keith W; Jäger, Hans Rolf; Werring, David J
• Other Names: author non-byline.; Harkness Kirsty author non-byline.; Shaw Louise author non-byline.; Sword Jane author non-byline.; Mohd Nor Azlisham author non-byline.; Sharma Pankaj author non-byline.; Veltkamp Roland author non-byline.; Kelly Deborah author non-byline.; Harrington Frances author non-byline.; Randall Marc author non-byline.; Smith Matthew author non-byline.; Mahawish Karim author non-byline.; Elmarim Abduelbaset author non-byline.; Esisi Bernard author non-byline.; Cullen Claire author non-byline.; Nallasivam Arumug author non-byline.; Price Christopher author non-byline.; Barry Adrian author non-byline.; Roffe Christine author non-byline.; Coyle John author non-byline.; Hassan Ahamad author non-byline.; Lovelock Caroline author non-byline.; Birns Jonathan author non-byline.; Cohen David author non-byline.; Sekaran L author non-byline.; Parry-Jones Adrian author non-byline.; Parry Anthea author non-byline.; Hargroves David author non-byline.; Proschel Harald author non-byline.; Datta Prabel author non-byline.; Darawil Khaled author non-byline.; Manoj Aravindakshan author non-byline.; Burn Mathew author non-byline.; Patterson Chris author non-byline.; GialloMbardo Elio author non-byline.; Smyth Nigel author non-byline.; Mansoor Syed author non-byline.; Anwar Ijaz author non-byline.; Marsh Rachel author non-byline.; Ispoglou Sissi author non-byline.; Chadha Dinesh author non-byline.; Prabhakaran Mathuri author non-byline.; Meenakishundaram Sanjeevikumar author non-byline.; O'Connell Janice author non-byline.; Scott Jon author non-byline.; Krishnamurthy Vinodh author non-byline.; Aghoram Prasanna author non-byline.; McCormick Michael author non-byline.; Paul O'Mahony Nikola Sprigg author non-byline.; Lillian Choy Martin Cooper author non-byline.; Wilkinson Peter author non-byline.; Leach Simon author non-byline.; Caine Sarah author non-byline.; Burger Ilse author non-byline.; Gunathilagan Gunaratam author non-byline.; Guyler Paul author non-byline.; Emsley Hedley author non-byline.; Davis Michelle author non-byline.; Manawadu Dulka author non-byline.; Pasco Kath author non-byline.; Mamun Maam author non-byline.; Luder Robert author non-byline.; Sajid Mahmud author non-byline.; Anwar Ijaz author non-byline.; Okwera James author non-byline.; Staals Julie author non-byline.; Warburton Elizabeth author non-byline.; Saastamoinen Kari author non-byline.; England Timothy author non-byline.; Putterill Janet author non-byline.; Flossman Enrico author non-byline.; Power Michael author non-byline.; Dani Krishna author non-byline.; Mangion David author non-byline.; Suman Appu author non-byline.; Corrigan John author non-byline.; Lawrence Enas author non-byline.; Vahidassr Djamil author non-byline.;
• Is Part Of: Journal of neurology, neurosurgery and psychiatry. Volume 90:Issue 3(2019)
• Page Start: 320
• Page End: 325
• Publication Date: 2018-11-19
• Subjects: ischaemic stroke -- anticoagulation -- warfarin -- DOAC -- atrial fibrillation; Neurology -- Periodicals; Nervous system -- Surgery -- Periodicals; Psychiatry -- Periodicals; 616.8
• DOI: 10.1136/jnnp-2018-318890
• Languages: English
• ISSNs: 0022-3050

Abstract

Abstract : Background and purpose: The optimal time to start oral anticoagulant (OAC) in patients with ischaemic stroke due to non-valvular atrial fibrillation (AF) is unknown. We reviewed OAC timing in relation to 90-day clinical outcomes as a post hoc analysis from a prospective multicentre observational study. Methods: We included patients with data on time to initiation of OAC from CROMIS-2 (Clinical Relevence Of Microbleeds In Stroke-2), a prospective observational inception cohort study of 1490 patients with ischaemic stroke or transient ischaemic attack (TIA) and AF treated with OAC. The primary outcome was the composite outcome of TIA, stroke (ischaemic stroke or intracranial haemorrhage) or death within 90 days of the qualifying stroke or TIA. We performed adjusted logistic regression analyses to compare early (0–4 days) and later (≥5 days or never started) OAC initiation. Results: We included 1355 patients, mean age 76 (SD 10), 580 (43%) women. OAC was started early in 358 (26%) patients and later (or not at all) in 997 (74%) patients. The event rate within 90 days was 48/997 (5%) in the late-OAC group (2 intracranial haemorrhages, 18 ischaemic strokes or TIAs and 31 deaths (three deaths were as a result of new ischaemic strokes)) versus 7/358 (2%) in the early-OAC group (5 ischaemic strokes or TIAs and 2 deaths). In adjusted analyses, late OAC was not associated with the composite outcome (adjusted OR 1.17, 95% CI 0.48 to 2.84, p=0.736). Conclusion: In adjusted analyses, early OAC after acute ischaemic stroke or TIA associated with AF was not associated with a difference in the rate of the composite outcome of stroke, TIA or death at 90 days, compared with late OAC. However, despite adjustment for important baseline factors, patients selected for early OAC and late OAC might still have differed in important respects; evaluation of OAC timing in adequately powered randomised trials is required. Clinical trial registration: NCT02513316 .