HELSINKI, Finland– The benefits and drawbacks of early vs late initiation of a direct oral anticoagulant (OAC) after intense ischemic stroke in the setting of atrial fibrillation (AF) for secondary avoidance was the subject of a vibrant dispute at the Congress of the European Academy of Neurology 2024.
In an audience vote prior to the conversation, 77% voted yes to early anticoagulation, whereas 23% chose no early anticoagulation.
Arguing for early anticoagulation, Urs Fischer, MD, teacher of neurology at University Hospital Basel, Switzerland, informed delegates that neurologists deal with a problem after stroke in clients with AF.
“We are terrified of ischemic reoccurrence [if we don't start oral anticoagulation early]however on the other hand, if we do, we run the risk of hemorrhagic change (HT) and specifically intracranial hemorrhage (ICH). There is a great deal of stress and anxiety about this.”
Still, persistent ischemic stroke is less serious than an ICH is, he kept in mind.
The response to this problem basically comes down to what the net advantage of either of the 2 techniques remains in specific clients, Fischer included.
He went on to thoroughly examine the literature in this area before concluding that “there is no factor to postpone anticoagulation in individuals with intense ischemic stroke and AF.”
Opposing Fischer was Zuzana Gdovinova, MD, PhD, Department of Neurology, L. Pasteur University Hospital, P.J. Safarik University, Kosice, Slovakia.
“I will not discuss small or moderate strokes as there is absolutely nothing to flag about early treatment, rather the worry of bleeding remains in significant strokes,” she stated.
Compared to the world of scientific trials with centers of quality in stroke, in the real-world, smaller sized healthcare facilities are worried about prospective problems, so they typically start OAC later on, stated Gdovinova. Basically, the scientific choice boils down to dealing with the person, she stated.
“We understand that, in reality, we deal with older clients [who are often excluded from clinical trials]and they have a greater threat [than younger patients do] due to the fact that of comorbidities and polypharmacy. I believe this is a group– older clients– who we ought to be really cautious with in choosing on early anticoagulation,” Gdovinova included.
Session Chair Anita Arsovska, MD, PhD, head of Department for Urgent Neurology, University Clinic of Neurology, and teacher of neurology at University Ss Cyril and Methodius, Skopje, North Macedonia, concurred and backed the concept of a customized technique.
“We require to have more information on our clients, and in the future, we require to have more focused standards based upon whether the stroke is extreme or not, whether there is HT, and so on,” stated Arsovska.
She thinks that the present practice utilized by the majority of stroke centers of starting oral anticoagulation 3 or 4 days after small stroke, 6 or 7 days after moderate stroke, and as much as 14 days after a significant stroke will be gradually deserted.
Fischer summed up the most recent literature in this area,
