Optimal time to start non-vitamin K antagonist anticoagulants in acute ischemic stroke patients
Keywords:
non-vitamin K antagonist anticoagulants (NOACs), non-valvular atrial fibrillation, acute ischemic stroke, cardioembolic strokeAbstract
Abstract
About 13-26% of ischemic stroke is caused by non-valvular atrial fibrillation (NVAF). Currently, there is no randomized-controlled trial (RCT) that supports when to start anticoagulant optimally. Risk of recurrent ischemic stroke is high within first few weeks of onset, however early starting anticoagulants increases risk of hemorrhagic transformation. Non-vitamin K antagonist anticoagulants (NOACs) which have been studied in the past 10 years have at least equal efficacy as warfarin in prevention of ischemic stroke caused by NVAF. Moreover, NOACs reduced cases of intracranial hemorrhage compared to warfarin. However, 4 landmark NOACs studies did not enroll acute ischemic stroke patients.
There are a few small trials studied risk and benefit of early starting NOACs in mild to moderate acute ischemic stroke from NVAF. The studies showed that early stating NOACs was less likely to increase risk of any intracranial hemorrhage. While starting NOACs later associated with increasing rate of recurrent ischemic stroke. Currently, there are several ongoing randomized-controlled trials that have power to answer
whether starting NOACs early or later after onset of acute ischemic stroke will be an ideal in terms of efficacy and safety.
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