WSC 2026 | Anticoagulation after AF-related stroke: what is settled and which subgroups remain uncertain?

There were four randomized control trials, the ELAN trial, the OPTIMAS trial, the START trial, and the TIMING trial. And they were all addressing the same question, when can we start direct oral anticoagulants in people with AF-related stroke? At the time, the physicians were scared that when starting DOACs early, that they produce intracerebral and intracranial hemorrhages, which could, you know, be fatal. On the other hand, we knew that if we wait too long, patients will suffer a recurrent ischemic event. So therefore, this was a classical dilemma. And all these four trials were not able to show that an early DOAC initiation is superior to a later treatment start. However, they were able to show that at least it is safe. So that’s the reason why we performed an individual participant data meta-analysis of all these four trials. And what we could show is that an early treatment start within four days is superior to a later treatment start. However the next question is obviously can we start even earlier and we performed individual participant data meta-analysis with a Bayesian approach where we could show that the earlier you start the treatment the better and we also could show that it is safe to start the treatment early. So with all these four trials, we have finally answered an unanswered clinical question. So one particular subgroup where I’m still concerned are people with relevant hemorrhagic transformation after the ischemic stroke, especially if it occurs early. So we do not know whether it is really safe and effective to start early DOAC in these people because they were partially excluded from the randomized control trials. Even though there are no major hints that you do have any excess in bleeding complications, we have to be cautious and more data are obviously needed. And the other subgroup where we are a little bit in the grey zone are the people with the massive ischemic stroke. Even though subgroups were not showing any harm, there were only few patients with massive strokes in the four trials I mentioned before. What we certainly know is you should not start to work early in people with intracellular damage.

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