A recent international clinical study led by the Inselspital, Universitätsspital Bern, and the University of Bern has demonstrated that anticoagulation (blood thinning) treatment can be initiated earlier in patients with stroke and atrial fibrillation than previously recommended in medical guidelines.
This earlier intervention could decrease the likelihood of another stroke without heightening the risk of bleeding. The study’s findings were published in the New England Journal of Medicine.
Context
Around 80% of strokes are caused by a blockage in an artery within the brain (ischemia).
Up to 20% of these are due to blood clots formed in the hearts of patients with atrial fibrillation, an irregular heart rhythm affecting up to 5% of individuals over 65.
Direct oral anticoagulants (DOACs) are blood thinners used to prevent blood clots in patients with atrial fibrillation.
The timing of the commencement of this treatment following a stroke has remained ambiguous due to the possible increase in the risk of bleeding, which could be most significant in the first few days post-stroke.
However, the potential benefits of these drugs could also be most pronounced during this period.
Study Details and Results
The ELAN study (Early versus Late initiation of direct oral anticoagulants in post-ischemic stroke patients with atrial fibrillation) investigated this issue.
It demonstrated that starting anticoagulant treatment earlier likely reduces the risk of subsequent stroke events, without increasing the risk of complications.
The study, which ran from 2013, involved patients with acute ischemic stroke and atrial fibrillation recruited from 103 different stroke units across 15 countries in Europe, the Middle East, and Asia between 2017 and 2022.
Depending on stroke severity and location, participants were randomly allocated to begin treatment earlier or later than guideline recommendations.
The study found that 2.9% of participants (29 people) in the early treatment group and 4.1% of participants (41 people) in the late treatment group experienced one of the aforementioned events after 30 days.
After 90 days, the event rate difference between the two groups was -1.9%.
New strokes occurred after 30 days in 1.4% of early-treated participants (14 people) and in 2.5% of late-treated participants (25 people).
Symptomatic cerebral hemorrhages occurred in 0.2% of participants (2 people) in both groups.
Comments and Future Steps
“Our study provides scientific evidence for a common dilemma in early secondary prevention after ischemic stroke.
Given our results, an early start of treatment makes sense when it is indicated or desirable for logistical or other reasons,” stated Prof. Urs Fischer from the university hospitals in Bern and Basel.
Prof. Dr. Jesse Dawson of the University of Glasgow added that the study also suggests that early blood thinning carries only a small risk of cerebral hemorrhage, particularly when treatment is based on imaging selection.
The researchers plan to investigate if the risk and benefit are consistent across different subgroups of the ELAN study participants in the next step, especially among those more severely affected.
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The study was published in the New England Journal of Medicine.
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