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

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 .