Early vs Late Anticoagulation After Ischemic Stroke in Patients With Atrial Fibrillation and Covert Brain Infarcts

BACKGROUND AND OBJECTIVES: Covert brain infarcts (CBIs) in patients with first-ever ischemic stroke (IS) and atrial fibrillation (AF) are associated with an increased risk of stroke recurrence. We aimed to assess whether CBIs modify the treatment effect of early vs late initiation of direct oral anticoagulants (DOACs) in patients with IS and AF. METHODS: values. RESULTS: for interaction: 0.063). With early DOAC treatment, IS recurrence risk was lower in participants with CBI (aRD: -2.7%, 95% CI -5.0 to -0.4), but not in participants without CBI (aRD: -0.4, 95% CI -2.1 to 1.2). No sICH was observed in the early treatment group. DISCUSSION: The presence of CBI may indicate a subgroup of patients with first-ever IS and AF who particularly benefits from early DOAC initiation to prevent ischemic event recurrence, without increasing harm. Our findings should be considered in clinical decision making regarding timely DOAC treatment in patients with stroke and AF. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that in patients with covert brain infarcts, atrial fibrillation, and first-ever ischemic stroke, early (vs late) initiation of DOACs is associated with lower risk of recurrent stroke with no increase in harm. TRIAL REGISTRATION INFORMATION: : November 6, 2017.