Article Impact Level: HIGH Data Quality: STRONG Summary of JAMA Neurology. https://doi.org/10.1001/jamaneurol.2024.1450 Dr. Martina Goeldlin et al.
Points
- Post hoc analysis of the ELAN trial assessed the safety and efficacy of early vs late direct oral anticoagulation (DOAC) initiation after ischemic stroke in individuals with atrial fibrillation.
- The study included 1962 participants and found that the odds of the primary outcome were similar for early vs late DOAC initiation among participants with minor, moderate, and major stroke.
- Early DOAC treatment was not associated with a higher rate of bleeding complications, including symptomatic intracranial hemorrhage, or any adverse events regardless of infarct size, including major stroke.
- The analysis, conducted across over 100 sites in 15 countries, revealed consistent safety and efficacy of early vs late DOAC initiation across different infarct sizes as assessed by brain imaging.
- The findings suggest that infarct size did not modify the safety and efficacy of early vs. late DOAC initiation in people with ischemic stroke and atrial fibrillation, emphasizing the potential benefits of early DOAC treatment in this patient population.
Summary
In a post hoc analysis of the Early Versus Later Anticoagulation for Stroke With Atrial Fibrillation (ELAN) trial involving 1962 participants, the safety and efficacy of early vs late initiation of direct oral anticoagulation (DOAC) after ischemic stroke in people with atrial fibrillation were assessed. The primary outcome, which included recurrent ischemic stroke, symptomatic intracranial hemorrhage, extracranial bleeding, systemic embolism, or vascular death within 30 days, showed similar odds for early vs late DOAC initiation among participants with minor, moderate, and major stroke. Notably, early DOAC treatment was not associated with a higher rate of bleeding complications, particularly symptomatic intracranial hemorrhage, or any adverse events regardless of infarct size, including major stroke.
The study, conducted between October 2017 and December 2022 across more than 100 sites in 15 countries, revealed that the treatment effect of early DOAC initiation did not differ in people with minor, moderate, or major stroke as assessed by brain imaging. The primary outcome occurred in 2.7% of participants with early DOAC initiation vs. 3.0% with late DOAC initiation among those with minor stroke, 2.8% vs. 3.6% among those with moderate stroke, and 3.7% vs. 7.0% among those with major stroke. Notably, there was no significant treatment interaction for the primary outcome, indicating that the safety and efficacy of early vs. late DOAC initiation were consistent across different infarct sizes.
In conclusion, the findings from this post hoc analysis of the ELAN trial suggest that infarct size did not modify the safety and efficacy of early vs. late DOAC initiation in people with ischemic stroke and atrial fibrillation. Early DOAC treatment was not associated with a higher rate of adverse events, particularly symptomatic intracranial hemorrhage, for any infarct size, including major stroke, highlighting the potential benefits of early DOAC initiation in this patient population.
Link to the article: https://jamanetwork.com/journals/jamaneurology/article-abstract/2819377
References Goeldlin, M. B., Hakim, A., Branca, M., Abend, S., Kneihsl, M., Valenzuela Pinilla, W., Fenzl, S., Rezny-Kasprzak, B., Rohner, R., Strbian, D., Paciaroni, M., Thomalla, G., Michel, P., Nedeltchev, K., Gattringer, T., Sandset, E. C., Bonati, L., Aguiar De Sousa, D., Sylaja, P. N., … Pencz, Z. (2024). Early vs Late Anticoagulation in Minor, Moderate, and Major Ischemic Stroke With Atrial Fibrillation Post Hoc Analysis of the ELAN Randomized Clinical Trial. JAMA Neurology. https://doi.org/10.1001/jamaneurol.2024.1450
