Early versus Later Anticoagulation for Stroke with Atrial Fibrillation

   This randomized open-label trial (ELAN) evaluated the safety and efficacy of early versus later initiation of direct oral anticoagulants (DOACs) in 2013 patients with atrial fibrillation after ischemic stroke. Patients were stratified by infarct size (minor, moderate, major) and randomized across 103 international sites. Early anticoagulation began within 48 hours for minor/moderate stroke or day 6–7 for major stroke; later treatment followed the 1-3-6-12-day guideline. At 30 days, the composite outcome (ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death) occurred in 2.9% of early-treatment patients vs. 4.1% with later treatment (risk difference: –1.18 percentage points; 95% CI: –2.84 to 0.47). Early DOACs reduced recurrent ischemic stroke risk without increasing hemorrhagic events. At 90 days, composite events remained similar, supporting the safety of early imaging-guided DOAC initiation.

   This randomized open-label trial (ELAN) evaluated the safety and efficacy of early versus later initiation of direct oral anticoagulants (DOACs) in 2013 patients with atrial fibrillation after ischemic stroke. Patients were stratified by infarct size (minor, moderate, major) and randomized across 103 international sites. Early anticoagulation began within 48 hours for minor/moderate stroke or day 6–7 for major stroke; later treatment followed the 1-3-6-12-day guideline. At 30 days, the composite outcome (ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death) occurred in 2.9% of early-treatment patients vs. 4.1% with later treatment (risk difference: –1.18 percentage points; 95% CI: –2.84 to 0.47). Early DOACs reduced recurrent ischemic stroke risk without increasing hemorrhagic events. At 90 days, composite events remained similar, supporting the safety of early imaging-guided DOAC initiation.