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Objectives: Identify the complications associated with early initiation of anticoagulation after an atrial fibrillation associated ischemic stroke.
List differences between guideline recommendations regarding the initiation of anticoagulation after an ischemic stroke. Describe limitations of the available literature addressing the timing of anticoagulation initiation after an atrial fibrillation associated ischemic stroke.
Describe patients who could be considered for early initiation of anticoagulation after an atrial fibrillation associated ischemic stroke. After an atrial fibrillation associated ischemic stroke, the risk of recurrence of ischemic stroke within the subsequent 14 days increases by 0.
Therefore, optimizing the timing of anticoagulation initiation proves to be a complex, yet common, challenge after an atrial fibrillation associated ischemic stroke.
The risk of recurrent ischemic stroke and the risk of hemorrhagic transformation are two key considerations when determining the timing of anticoagulation initiation.
While warfarin has served as the mainstay anticoagulant for patients with atrial fibrillation, direct oral anticoagulants DOACs have also proven to be efficacious for secondary prevention of stroke in patients with atrial fibrillation.
However, the landmark trials that established the role of DOACs in stroke prevention in patients with atrial fibrillation largely excluded patients with recent ischemic strokes Table 1.
Guideline Review Current guidelines addressing the management of patients with stroke offer varying strategies of initiating anticoagulation.
In patients at high risk for hemorrhagic conversion ex.
Patients who experience a transient ischemic attack TIA should start anticoagulation one day after the event. Although the ESC guidelines provide more specific recommendations, the recommendations are based on expert opinion.
The RAF study evaluated the risk of recurrent ischemic events and severe bleeding in patients with acute stroke and atrial fibrillation and sought to identify the risk factors for these events.
Mean time to anticoagulation initiation after ischemic stroke onset was 8.
An adjusted analysis determined that anticoagulation initiation between four to 14 days from stroke onset was associated with a significant decrease in all outcome events HR: 0.
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