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Multicenter Study
. 2024 Sep 18;11(2):e002688.
doi: 10.1136/openhrt-2024-002688.

Timing of oral anticoagulation in atrial fibrillation patients after acute ischaemic stroke and outcome after 3 months: results of the multicentre Berlin Atrial Fibrillation Registry

Manuel C Olma  1 , Serdar Tütüncü  2 , Katrin Hansen  2 , Ulrike Grittner  2 , Claudia Kunze  2 , Joanna Dietzel  3 , Johannes Schurig  4 , Boris Dimitrijeski  5 , Georg Hagemann  6 , Frank Hamilton  7 , Martin Honermann  8 , Gerhard Jan Jungehuelsing  9 , Andreas Kauert  10 , Hans-Christian Koennecke  11 , Bruno-Marcel Mackert  7 , Darius G Nabavi  5 , Ingo Schmehl  12 , Paul Sparenberg  12 , Robert Stingele  13 , Enrico Voelzke  14 , Carolin Waldschmidt  15 , Daniel Zeise-Wehry  6 , Peter U Heuschmann  16   17 , Matthias Endres  1   2   18   19   20 , Karl Georg Haeusler  21
Affiliations
Multicenter Study

Timing of oral anticoagulation in atrial fibrillation patients after acute ischaemic stroke and outcome after 3 months: results of the multicentre Berlin Atrial Fibrillation Registry

Manuel C Olma et al. Open Heart. .

Abstract

Background: Oral anticoagulation (OAC) is key in stroke prevention in patients with atrial fibrillation (AF) but there is uncertainty regarding the optimal timing of OAC (re)initiation after stroke, as recent large randomised controlled trials have methodological weaknesses and excluded stroke patients on therapeutic anticoagulation at stroke onset as well as patients started on a vitamin K antagonist after stroke. The '1-3-6-12 days rule', based on expert consensus and referring to stroke severity, was used in clinical practice to initiate OAC after acute ischaemic stroke or transient ischaemic attack (TIA) since publication in 2013.

Methods: We retrospectively assessed whether compliance to the '1-3-6-12 days rule' was associated with the composite endpoint (recurrent stroke, systemic embolism, myocardial infarction, major bleeding or all-cause death).

Results: Among 708 registry patients with known AF before stroke and hospitalisation within 72 hours after stroke, 432 were anticoagulated at stroke onset. OAC was started according to the '1-3-6-12 days rule' in 255 (39.2%) patients. Non-adherence to the '1-3-6-12 days rule' was not associated with the composite endpoint within 3 months in 661 patients who (re-)started on OAC (log-rank test: p=0.74).Results were similar for 521 patients (re)started on a non-vitamin K-dependent OAC.

Conclusion: (Re)starting OAC after stroke followed the '1-3-6-12 days rule' in about 40% of all patients with AF, and more often in those anticoagulated at stroke onset. Adherence to the '1-3-6-12 days rule' did not reduce the composite clinical endpoint, if OAC was restarted within 3 months of stroke/TIA.

Trial registration number: NCT02306824.

Keywords: Arrhythmias, Cardiac; Atrial Fibrillation; STROKE.

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Conflict of interest statement

Competing interests: DGN reports speaker's honoraria and/or consulting fees from AstraZeneca, Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Novartis, Pfizer and Sanofi. PUH reports grants from Charité – Universitätsmedizin Berlin (within Mondafis; supported by an unrestricted research grant to the Charité from Bayer), research grants from German Ministry of Research and Education, German Research Foundation, research grants from Bavarian State, European Union, German Parkinson Society, German Cancer Aid, University Hospital Würzburg, German Heart Foundation, Federal Joint Committee (G-BA) within the Innovationsfonds, University Hospital Heidelberg (within RASUNOA-prime; supported by an unrestricted research grant to the University Hospital Heidelberg from Bayer, BMS, Boehringer-Ingelheim, Daiichi Sankyo), University Göttingen (within FIND-AF randomised; supported by an unrestricted research grant to the University Göttingen from Boehringer-Ingelheim) outside the submitted work; and participated on Data, Safety Monitoring Board in publicly funded studies (by German Research Foundation, German Ministry of Research, Foundations). ME reports grants from Bayer and fees paid to the Charité from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Covidien, Daiichi Sankyo, Glaxo Smith Kline, Novartis, Pfizer and Sanofi,all outside the submitted work. KGH reports speaker's honoraria, consulting fees, lecture honoraria and/or study grants from Abbott, Amarin; AstraZeneca, Bayer Healthcare, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Daiichi Sankyo, Edwards Lifesciences, Medronic, Novartis, Pfizer, Portola, Premier Research, Sanofi, SUN Pharma, and W.L. Gore and Associates. PS reports speaker's honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb and Pfizer.

Figures

Figure 1
Figure 1. Derivation of the analysed cohort of Berlin Atrial Fibrillation registry patients. AF, atrial fibrillation; OAC, oral anticoagulant; TIA, transient ischaemic attack.
Figure 2
Figure 2. Kaplan-Meier curve for the probability of composite endpoint (recurrent ischaemic stroke or TIA, systemic embolism, myocardial infarction, haemorrhagic stroke, extracranial major bleed or all-cause death) within 3 months after the index stroke/TIA: (A) in registry patients without OAC after stroke, censoring patients who (re)started OAC; (B) in registry patients with (re)started OAC (early, timely or late) according to the ‘1–3–6–12 days rule’. Log-rank test was used to test group differences. OAC, oral anticoagulant; TIA, transient ischaemic attack.
See this image and copyright information in PMC

References

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