Written by Mary Marschner
Spoon Feed
Starting anticoagulation with a direct oral anticoagulant (DOAC) in patients with atrial fibrillation within 4 days of an acute stroke is noninferior to starting it between 7-14 days.
Synopsis
The OPTIMAS trial is a multicenter, blinded-endpoint, phase 4 randomized controlled trial conducted across 100 UK hospitals, involving adults with atrial fibrillation and acute ischemic stroke. It compared early (≤ 4 days) versus delayed (7–14 days) initiation of DOACs. Primary findings revealed no statistically significant difference in the composite outcome (recurrent ischemic stroke, intracranial hemorrhage, or systemic embolism) between groups at 90 days (adjusted risk difference 0.000, 95%CI -0.011 to 0.012), establishing noninferiority (p=0.0003). Secondary outcomes showed similar safety profiles, including intracranial hemorrhage and extracranial bleeding. These findings challenge current guideline-based delays in DOAC initiation after ischemic stroke. (AI-generated)
Early DOACs – no extra bleeding
Wouldn’t it be nice to have a specific time to start anticoagulating a patient who had an acute stroke and has atrial fibrillation? Our gut tells us infarcted brain tissue is more friable in the days after a stroke and more likely to bleed if we start a DOAC early, but this paper indicates that perhaps we have been too conservative. It was a large, multicenter, randomized study and showed that starting a DOAC early (within 4 days) was noninferior to starting it 7-14 days later. The primary outcome was a composite, which I initially didn’t like, because my concern with starting a DOAC was bleeding – not necessarily bleeding AND recurrent ischemic stroke AND systemic embolism. However, when I drilled down, there wasn’t a statistical difference in any of the subcategories, and the number of bleeding events, recurrent strokes, systemic embolisms was overall small. Will this study change my practice? Yes, I will feel more comfortable starting anticoagulation within 4 days of an acute stroke and less scared of a bleed. But I am also reassured that among all 3,621 patients, there was no statistical difference in the incidence of systemic embolism or recurrent ischemic stroke between early and late initiation of DOACs either. The choice is for you and your patient to decide together.
Source
Optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS): a multicentre, blinded-endpoint, phase 4, randomised controlled trial. Lancet. 2024 Oct 23:S0140-6736(24)02197-4. doi: 10.1016/S0140-6736(24)02197-4. Epub ahead of print. PMID: 39491870
