Non-vitamin K antagonist oral anticoagulants may prevent ischemic stroke in AF patients: Study

Sweden: Following an acute ischemic stroke in individuals with atrial fibrillation, early commencement of non-vitamin K antagonist oral anticoagulants (NOACs) was non-inferior to delayed initiation, says an article published in Circulation Journal.

When non-vitamin K antagonist oral anticoagulants should be started in individuals with atrial fibrillation who have experienced an acute ischemic stroke, there are no evidence-based guidelines. In order to ascertain the effectiveness and safety of early vs delayed commencement of NOAC in these patients, Jonas Oldgren and colleagues carried out this study.

The Swedish Stroke Register was used for recruitment and follow-up in the registry-based, randomized, noninferiority, open-label, blinded TIMING (Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation) end-point study at 34 stroke hospitals. Within 72 hours of the stroke, patients were randomized to begin taking NOACs sooner (4 days) or later (5–10 days), with the choice of NOAC being left up to the investigators. The main result was a composite of 90-day death from all causes, symptomatic intracerebral hemorrhage, or recurrent ischemic stroke. 

The key findings of this study were:

1. 888 patients were randomly assigned between April 2, 2017, and December 30, 2020, to either an early (n=450) or a delayed (n=438) commencement of NOAC.

2. No patient was misplaced throughout the 90-day follow-up.

3. The average age was 78.3 years (SD, 9.9 years); 46.2% of the population was female; 49.1% had a history of atrial fibrillation, and 17.5% had had a stroke before.

4. 38 patients (8.68%) allocated to delayed NOAC beginning and 31 patients (6.89%) assigned to early initiation both experienced the main result.

5. In the early and delayed groups, ischemic stroke rates were 3.11% and 4.57%, while all-cause death rates were 4.67% and 5.71%, respectively.

6. There were no symptomatic intracerebral hemorrhages in either group of patients.

In conclusion, the early initiation of NOAC was found safe and should be taken into consideration for acute secondary stroke prevention in patients suitable for NOAC treatment due to the numerically decreased risks of ischemic stroke and mortality and the absence of symptomatic intracerebral hemorrhages.

Reference: 

Oldgren, J., Åsberg, S., Hijazi, Z., Wester, P., Bertilsson, M., Norrving, B., & National TIMING Collaborators. (2022). Early versus delayed non-vitamin K antagonist Oral Anticoagulant Therapy after acute ischemic stroke in atrial fibrillation (TIMING): A registry-based randomized controlled noninferiority study. Circulation, https://doi.org/10.1161/CIRCULATIONAHA.122.060666