Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis
Background and Purpose Antiplatelets are often used before direct oral anticoagulant (DOACs) initiation after an acute ischemic stroke related to atrial fibrillation (AF), but the evidence is weak. Here, we explored the risks and benefits of this approach. Methods A post-hoc analysis of ELAN (Early...
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Korean Stroke Society
2025-05-01
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| Series: | Journal of Stroke |
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| Online Access: | http://j-stroke.org/upload/pdf/jos-2024-04322.pdf |
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| author | Alexandros A. Polymeris Masatoshi Koga Daniel Strbian Adhiyaman Vedamurthy Manju Krishnan Mattia Branca Thomas Horvath Martina Goeldlin Gek Shim Christoph Gumbinger Liqun Zhang Espen Saxhaug Kristoffersen Philippe Desfontaines Peter Vanacker Angelika Alonso Sven Poli Ana Paiva Nunes Nicoletta G. Caracciolo Markus Kneihsl Timo Kahles Daria Giudici Silja Räty Marjaana Tiainen Jesse Dawson Urs Fischer for the ELAN Investigators |
| author_facet | Alexandros A. Polymeris Masatoshi Koga Daniel Strbian Adhiyaman Vedamurthy Manju Krishnan Mattia Branca Thomas Horvath Martina Goeldlin Gek Shim Christoph Gumbinger Liqun Zhang Espen Saxhaug Kristoffersen Philippe Desfontaines Peter Vanacker Angelika Alonso Sven Poli Ana Paiva Nunes Nicoletta G. Caracciolo Markus Kneihsl Timo Kahles Daria Giudici Silja Räty Marjaana Tiainen Jesse Dawson Urs Fischer for the ELAN Investigators |
| author_sort | Alexandros A. Polymeris |
| collection | DOAJ |
| description | Background and Purpose Antiplatelets are often used before direct oral anticoagulant (DOACs) initiation after an acute ischemic stroke related to atrial fibrillation (AF), but the evidence is weak. Here, we explored the risks and benefits of this approach. Methods A post-hoc analysis of ELAN (Early versus Late Initiation of Direct Oral Anticoagulants in Post-ischemic Stroke Patients with Atrial Fibrillation) trial data (NCT03148457) was conducted to compare the risk of recurrent ischemic stroke, systemic embolism, major bleeding (extracranial or intracranial hemorrhage [ICH]), and vascular death within 30 days (as a composite and as individual outcomes) in participants treated with and without antiplatelets before DOAC initiation after an AF-associated ischemic stroke. We used both logistic and cause-specific Cox proportional hazards regression in inverse probability of treatment weighted models to account for confounding. We calculated the net benefit of antiplatelet use by subtracting the weighted rate of excess bleeding events attributable to antiplatelets from the rate of excess ischemic events possibly prevented by antiplatelets. Results Among 2,013 participants (median age 77 years, 45.5% female), 1,090 (54.1%) used antiplatelets, and 70 (3.5%) experienced the composite outcome. Antiplatelet use was not associated with the composite outcome (inverse probability of treatment weighted odds ratio [ORweighted] 1.06, 95% confidence interval [CI] 0.66–1.72; inverse probability of treatment weighted hazard ratio [HRweighted] 1.06, 95% CI 0.65–1.72), but showed a lower risk of ischemic stroke recurrence (ORweighted 0.58 [0.30–1.08], HRweighted 0.57 [0.30–1.10]), and a higher risk of major bleeding (ORweighted 1.76 [0.56–6.63], HRweighted 1.88 [0.56–6.39]). Its net benefit was +0.57 (95% CI -1.25 to +2.34) to +0.30 (-1.82 to +2.27) weighted events/100 person-months for ICH weights 1.5 to 3.1. Conclusion Following an AF-associated ischemic stroke, we found a lower risk of recurrence and no signs of net harm with antiplatelet use before DOAC initiation, despite an increased risk of bleeding. |
| format | Article |
| id | doaj-art-1ed18d91c87a48fea779c2888a4372e5 |
| institution | Kabale University |
| issn | 2287-6391 2287-6405 |
| language | English |
| publishDate | 2025-05-01 |
| publisher | Korean Stroke Society |
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| series | Journal of Stroke |
| spelling | doaj-art-1ed18d91c87a48fea779c2888a4372e52025-08-20T03:46:46ZengKorean Stroke SocietyJournal of Stroke2287-63912287-64052025-05-0127221722710.5853/jos.2024.04322582Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial AnalysisAlexandros A. Polymeris0Masatoshi Koga1Daniel Strbian2Adhiyaman Vedamurthy3Manju Krishnan4Mattia Branca5Thomas Horvath6Martina Goeldlin7Gek Shim8Christoph Gumbinger9Liqun Zhang10Espen Saxhaug Kristoffersen11Philippe Desfontaines12Peter Vanacker13Angelika Alonso14Sven Poli15Ana Paiva Nunes16Nicoletta G. Caracciolo17Markus Kneihsl18Timo Kahles19Daria Giudici20Silja Räty21Marjaana Tiainen22Jesse Dawson23Urs Fischer24for the ELAN Investigators Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland Glan Clwyd Hospital, Betsi Cadwaladr University Local Health Board, Rhyl, UK Stroke Unit, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK Department of Clinical Research, Clinical Trial Unit (CTU) Bern, University of Bern, Bern, Switzerland Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland University Hospital of North Durham, Durham, UK Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany Department of Neurology, St George’s University Hospital, London, UK Department of Neurology, Akershus University Hospital, Lørenskog, Norway Stroke Unit, Department of Neurology, CHC-Groupe Santé, Liège, Belgium Department of Neurology, AZ Groeninge, Kortrijk, Belgium Department of Neurology, University Medical Center Mannheim and Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany Internal Medicine, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal Department of Human Neurosciences, University La Sapienza, Rome, Italy Department of Neurology, Medical University of Graz, Graz, Austria Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, Queen Elizabeth University Hospital, Glasgow, UK Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, SwitzerlandBackground and Purpose Antiplatelets are often used before direct oral anticoagulant (DOACs) initiation after an acute ischemic stroke related to atrial fibrillation (AF), but the evidence is weak. Here, we explored the risks and benefits of this approach. Methods A post-hoc analysis of ELAN (Early versus Late Initiation of Direct Oral Anticoagulants in Post-ischemic Stroke Patients with Atrial Fibrillation) trial data (NCT03148457) was conducted to compare the risk of recurrent ischemic stroke, systemic embolism, major bleeding (extracranial or intracranial hemorrhage [ICH]), and vascular death within 30 days (as a composite and as individual outcomes) in participants treated with and without antiplatelets before DOAC initiation after an AF-associated ischemic stroke. We used both logistic and cause-specific Cox proportional hazards regression in inverse probability of treatment weighted models to account for confounding. We calculated the net benefit of antiplatelet use by subtracting the weighted rate of excess bleeding events attributable to antiplatelets from the rate of excess ischemic events possibly prevented by antiplatelets. Results Among 2,013 participants (median age 77 years, 45.5% female), 1,090 (54.1%) used antiplatelets, and 70 (3.5%) experienced the composite outcome. Antiplatelet use was not associated with the composite outcome (inverse probability of treatment weighted odds ratio [ORweighted] 1.06, 95% confidence interval [CI] 0.66–1.72; inverse probability of treatment weighted hazard ratio [HRweighted] 1.06, 95% CI 0.65–1.72), but showed a lower risk of ischemic stroke recurrence (ORweighted 0.58 [0.30–1.08], HRweighted 0.57 [0.30–1.10]), and a higher risk of major bleeding (ORweighted 1.76 [0.56–6.63], HRweighted 1.88 [0.56–6.39]). Its net benefit was +0.57 (95% CI -1.25 to +2.34) to +0.30 (-1.82 to +2.27) weighted events/100 person-months for ICH weights 1.5 to 3.1. Conclusion Following an AF-associated ischemic stroke, we found a lower risk of recurrence and no signs of net harm with antiplatelet use before DOAC initiation, despite an increased risk of bleeding.http://j-stroke.org/upload/pdf/jos-2024-04322.pdfatrial fibrillationischemic strokeanticoagulantstimingantiplateletsantiplatelet bridging |
| spellingShingle | Alexandros A. Polymeris Masatoshi Koga Daniel Strbian Adhiyaman Vedamurthy Manju Krishnan Mattia Branca Thomas Horvath Martina Goeldlin Gek Shim Christoph Gumbinger Liqun Zhang Espen Saxhaug Kristoffersen Philippe Desfontaines Peter Vanacker Angelika Alonso Sven Poli Ana Paiva Nunes Nicoletta G. Caracciolo Markus Kneihsl Timo Kahles Daria Giudici Silja Räty Marjaana Tiainen Jesse Dawson Urs Fischer for the ELAN Investigators Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis Journal of Stroke atrial fibrillation ischemic stroke anticoagulants timing antiplatelets antiplatelet bridging |
| title | Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis |
| title_full | Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis |
| title_fullStr | Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis |
| title_full_unstemmed | Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis |
| title_short | Antiplatelet Use Prior to Anticoagulant Initiation in Patients With Atrial Fibrillation-Related Ischemic Stroke: An ELAN Trial Analysis |
| title_sort | antiplatelet use prior to anticoagulant initiation in patients with atrial fibrillation related ischemic stroke an elan trial analysis |
| topic | atrial fibrillation ischemic stroke anticoagulants timing antiplatelets antiplatelet bridging |
| url | http://j-stroke.org/upload/pdf/jos-2024-04322.pdf |
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