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Patient Evidence Summary
Doctor, I have atrial fibrillation and just had a stroke. How soon can I be started on a blood thinner to protect me from another stroke?
For patients with atrial fibrillation who recently had a stroke, starting blood thinners known as DOACs within 4 days compared to 7 to 14 days after a stroke appears to be safe and effective.
Study highlights
For patients with atrial fibrillation and a new stroke, there was no difference in the combination of recurrent strokes, intracranial hemorrhage, and systemic embolization when starting DOACs within 4 days after a stroke vs waiting 7 to 14 days after a stroke.
Please note: these results do not apply to people who need to take warfarin, have another medical condition which makes taking a DOAC unsafe, or already have severe bleeding in their brain from their stroke.
Understanding the problem
Atrial fibrillation is an abnormal heart rhythm that is one of the most common causes of strokes. Many people are started on blood thinners, such as DOACs (e.g., apixaban, rivaroxaban, edoxaban, dabigatran), to decrease their risk of stroke. However, blood thinners also increase the risk of bleeding, such as bleeding in the brain (intracranial hemorrhage) after a stroke.
In the first few days after a stroke, there is a higher risk of having another stroke, but also a higher risk of intracranial hemorrhage due to damage to the brain tissue caused by the stroke. As a result, blood thinners are often not started for 1 to 2 weeks after a stroke, especially if it is a large stroke. While starting a blood thinner earlier might decrease the risk of having more strokes, it could also increase the risk of intracranial hemorrhage. Therefore, doctors are often unsure of what to do.
The researchers wanted to know whether starting DOACs earlier after a stroke was as safe and effective as waiting 1-2 weeks to start DOACs. In particular, they wanted to know if there was a difference in the combination of recurrent strokes, intracranial hemorrhage, and systemic embolization within 90 days of a stroke.
Who? The study included 3621 people (average age, 78 years; 55% were male) who had atrial fibrillation and a recent stroke and were going to be started on a DOAC (such as apixaban, rivaroxaban, edoxaban, or dabigatran) by their doctor. The study did not include people who needed to take warfarin, had another medical condition which made taking a DOAC unsafe, or had severe bleeding in their brain from their stroke.
What? The study compared early DOAC start (within 4 days of a stroke) with delayed DOAC start (7-14 days after a stroke).
Early DOAC Start (within 4 days of a stroke) | vs | Delayed DOAC Start (7-14 days after a stroke) |
|---|---|---|
It was up to the patient's doctor to decide which DOAC and which dose of the DOAC was used. The patient's doctor also decided which day, between 1 to 4 days after the stroke, to start the DOAC. This decision may have been influenced by how much of the patient's brain was damaged by the stroke. | It was up to the patient's doctor to decide which DOAC and which dose of the DOAC was used. The patient's doctor also decided which day, between 7 to 14 days after the stroke, to start the DOAC. This decision may have been influenced by how much of the patient's brain was damaged by the stroke. |
Early DOAC start (within 4 days of a stroke) vs delayed DOAC start (7-14 days after a stroke) in patients who have atrial fibrillation and a recent stroke
Outcomes at 90 days | Rate of events with early DOAC start (within 4 days of a stroke) | Rate of events with delayed DOAC start (7-14 days after a stroke) | Results |
|---|---|---|---|
Recurrent stroke, intracranial hemorrhage, and systemic embolization | About 3 out of 100 people | About 3 out of 100 people | No difference |
Recurrent stroke | About 2 out of 100 people | About 2 out of 100 people | No difference |
| Intracranial hemorrhage | About 1 out of 100 people | About 1 out of 100 people | No difference |
| Death | About 9 out of 100 people | About 9 out of 100 people | No difference |
| Major bleeding | About 1 out of 100 people | About 1 out of 100 people | No difference |
This Evidence Summary is based on the following article:
Werring DJ, Dehbi HM, Ahmed N, et al. 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. PubMed
Kevin Chien, MD
Kevin Chien is a General Internal Medicine and Thrombosis fellow at McMaster University. He completed his internal medicine residency at the University of Ottawa. His current research interests include the management of anticoagulation after bleeding.
Anthony Sandre, MD
Dr. Sandre is an Assistant Professor in the Division of General Internal Medicine at McMaster University with additional training in Vascular Medicine. Within the Division of Hematology and Thromboembolism, Dr. Sandre provides care to patients with arterial and venous thrombosis, arteriopathies, and high-risk primary or secondary prevention of cardiovascular disease.
Published: Monday, February 24, 2025
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
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This Evidence Summary was printed from the CLOT+ website on 2025/03/24. To view other Evidence Summaries or to register to receive email notifications about new Evidence Summaries, please visit us at https://plus.mcmaster.ca/ClotPlus/Articles/EvidenceSummaries |
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, McMaster University