Early Versus Late Initiation of Direct Oral Anticoagulants After Ischemic Stroke in People With Atrial Fibrillation and Hemorrhagic Transformation: Prespecified Subanalysis of the Randomized Controlled ELAN Trial

Still nothing that will prevent hemorrhagic transformation! Shouldn't that be a research priority that our stroke leadership ensures occurs? But since stroke has NO leadership, nothing ever gets done. The answer is; DON'T HAVE A STROKE!

Early Versus Late Initiation of Direct Oral Anticoagulants After Ischemic Stroke in People With Atrial Fibrillation and Hemorrhagic Transformation: Prespecified Subanalysis of the Randomized Controlled ELAN Trial

Roman Rohner, MD https://orcid.org/0009-0006-1331-705X, Markus Kneihsl, MD, PhD https://orcid.org/0000-0002-6334-9432, Martina B. Goeldlin, MD, PhD https://orcid.org/0000-0001-5800-116X, Arsany Hakim, MD https://orcid.org/0000-0001-9431-1069, Mattia Branca, PhD https://orcid.org/0000-0002-8063-7882, Stefanie Abend, BSc https://orcid.org/0009-0001-9901-9187, Waldo Valenzuela Pinilla, PhD https://orcid.org/0000-0002-6629-3366, … Show All … for the ELAN InvestigatorsAuthor Info & Affiliations

Circulation

Volume 150, Number 1

https://doi.org/10.1161/CIRCULATIONAHA.124.069324

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Abstract

BACKGROUND:

Whether hemorrhagic transformation (HT) modifies the treatment effect of early compared with late initiation of direct oral anticoagulation in people with ischemic stroke and atrial fibrillation is unknown.

METHODS:

This is a post hoc analysis of the ELAN trial (Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation). The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, major extracranial bleeding, systemic embolism, or vascular death within 30 days. Secondary outcomes were the individual components, 30- and 90-day functional outcome. We estimated outcomes based on HT, subclassified as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) on prerandomization imaging (core laboratory rating) using adjusted risk differences between treatment arms.

RESULTS:

Overall, 247 of 1970 participants (12.5%) had HT (114 HI 1, 77 HI 2, 34 PH 1, 22 PH 2). For the primary outcome, the estimated adjusted risk difference (early versus late) was −2.2% (95% CI, −7.8% to 3.5%) in people with HT (HI: −4.7% [95% CI, −10.8% to 1.4%]; PH: 6.1% [95% CI, −8.5% to 20.6%]) and −0.9% (95% CI, −2.6% to 0.8%) in people without HT. Numbers of symptomatic intracranial hemorrhage were identical in people with and without HT. With early treatment, the estimated adjusted risk difference for poor 90-day functional outcome (modified Rankin Scale score, 3–6) was 11.5% (95% CI, −0.8% to 23.8%) in participants with HT (HI: 7.4% [95% CI, −6.4% to 21.2%]; PH: 25.1% [95% CI, 0.2% to 50.0%]) and −2.6% (95% CI, −7.1% to 1.8%) in people without HT.

CONCLUSIONS:

We found no evidence of major treatment effect heterogeneity or safety concerns with early compared with late direct oral anticoagulation initiation in people with and without HT. However, early direct oral anticoagulation initiation may worsen functional outcomes in people with PH.

REGISTRATION:

URL: http://www.clinicaltrials.gov; Unique identifier: NCT03148457.