DOACs sooner or later after an ischaemic stroke with AF

There has been a theoretical concern that the starting DOACs after an ischaemic stroke with known AF may cause an increase in haemorrhagic transformation of the acute infarct.

A review of four RCTs examining the question of starting within the first 4 days or waiting 5 or more days¹. There was an improvement of the primary outcome, a composite of recurrent ischaemic stroke, symptomatic intracerebral haemorrhage 30 days 57 cases (2.1%) versus 83 (3.0%). This an NNT of 111 cases treated to get one benefit.

There was no difference in the symptomatic cerebral haemorrhage. The authors came out in favour of early intervention. Reference:

Collaboration on the optimal timing of anticoagulation after is ischaemic stroke and atrial fibrillation: a systematic review and prospective individual participant data meta-analysis of randomised controlled trials (CATALYST) Lancet (2025)

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