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Rohner R, Kneihsl M, Goeldlin MB, Hakim A, Branca M, Abend S, Valenzuela Pinilla W, Fenzl S, Rezny-Kasprzak B, Strbian D, Trelle S, Paciaroni M, Thomalla G, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Bonati L, Aguiar de Sousa D, Sylaja PN, Ntaios G, Koga M, Gdovinova Z, Lemmens R, Bornstein NM, Kelly P, Katan M, Horvath T, Dawson J, Fischer U. Early Versus Late Initiation of Direct Oral Anticoagulants After Ischemic Stroke in People With Atrial Fibrillation and Hemorrhagic Transformation: Prespecified Subanalysis of the Randomized Controlled ELAN Trial. Circulation 2024; 150:19-29. [PMID: 38753452 DOI: 10.1161/circulationaha.124.069324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Whether hemorrhagic transformation (HT) modifies the treatment effect of early compared with late initiation of direct oral anticoagulation in people with ischemic stroke and atrial fibrillation is unknown. METHODS This is a post hoc analysis of the ELAN trial (Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation). The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, major extracranial bleeding, systemic embolism, or vascular death within 30 days. Secondary outcomes were the individual components, 30- and 90-day functional outcome. We estimated outcomes based on HT, subclassified as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) on prerandomization imaging (core laboratory rating) using adjusted risk differences between treatment arms. RESULTS Overall, 247 of 1970 participants (12.5%) had HT (114 HI 1, 77 HI 2, 34 PH 1, 22 PH 2). For the primary outcome, the estimated adjusted risk difference (early versus late) was -2.2% (95% CI, -7.8% to 3.5%) in people with HT (HI: -4.7% [95% CI, -10.8% to 1.4%]; PH: 6.1% [95% CI, -8.5% to 20.6%]) and -0.9% (95% CI, -2.6% to 0.8%) in people without HT. Numbers of symptomatic intracranial hemorrhage were identical in people with and without HT. With early treatment, the estimated adjusted risk difference for poor 90-day functional outcome (modified Rankin Scale score, 3-6) was 11.5% (95% CI, -0.8% to 23.8%) in participants with HT (HI: 7.4% [95% CI, -6.4% to 21.2%]; PH: 25.1% [95% CI, 0.2% to 50.0%]) and -2.6% (95% CI, -7.1% to 1.8%) in people without HT. CONCLUSIONS We found no evidence of major treatment effect heterogeneity or safety concerns with early compared with late direct oral anticoagulation initiation in people with and without HT. However, early direct oral anticoagulation initiation may worsen functional outcomes in people with PH. REGISTRATION URL: http://www.clinicaltrials.gov; Unique identifier: NCT03148457.
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Affiliation(s)
- Roman Rohner
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Markus Kneihsl
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Martina B Goeldlin
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Mattia Branca
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Stefanie Abend
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Clinical Research, University of Bern, Switzerland (M.B., S.T.)
| | - Waldo Valenzuela Pinilla
- Support Center for Advanced Neuroimaging (W.V.P.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Sabine Fenzl
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Beata Rezny-Kasprzak
- University Institute of Diagnostic and Interventional Neuroradiology (R.R., A.H., S.F., B.R.-K.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Finland (D.S.)
| | | | - Maurizio Paciaroni
- Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy (M.P.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (G.T.)
| | - Patrik Michel
- Department of Neurology, University Hospital Lausanne, University of Lausanne, Switzerland (P.M.)
| | | | - Thomas Gattringer
- Department of Neurology (M. Kneihsl, T.G.), Medical University of Graz, Austria
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology (M. Kneihsl, T.G.), Medical University of Graz, Austria
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
| | - Leo Bonati
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
- Research Department, Reha Rheinfelden, Switzerland (L.B.)
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital and Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S.)
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India (P.N.S.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M. Koga)
| | - Zuzana Gdovinova
- Department of Neurology, P.J. Safarik University, Faculty of Medicine and University Hospital L. Pasteur Kosice, Slovakia (Z.G.)
| | - Robin Lemmens
- KU Leuven, Department of Neurosciences, Experimental Neurology; University Hospitals Leuven, Department of Neurology, Belgium (R.L.)
| | - Natan M Bornstein
- Department of Neurology, Shaare-Zedek Medical Center, Jerusalem, Israel (N.M.B.)
| | - Peter Kelly
- Stroke Clinical Trials Network Ireland, University College Dublin/Department of Neurology, Mater University Hospital (P.K.)
| | - Mira Katan
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
| | - Thomas Horvath
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, Queen Elizabeth University Hospital, University of Glasgow, UK (J.D.)
| | - Urs Fischer
- Department of Neurology (M.B.G., S.A., T.H., U.F.), Inselspital Bern University Hospital and University of Bern, Switzerland
- Department of Neurology, University and University Hospital Basel, Switzerland (M. Kneihsl, L.B., M. Katan, U.F.)
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Goeldlin MB, Hakim A, Branca M, Abend S, Kneihsl M, Valenzuela Pinilla W, Fenzl S, Rezny-Kasprzak B, Rohner R, Strbian D, Paciaroni M, Thomalla G, Michel P, Nedeltchev K, Gattringer T, Sandset EC, Bonati L, Aguiar de Sousa D, Sylaja PN, Ntaios G, Koga M, Gdovinova Z, Lemmens R, Bornstein NM, Kelly P, Katan M, Horvath T, Dawson J, Fischer U. Early vs Late Anticoagulation in Minor, Moderate, and Major Ischemic Stroke With Atrial Fibrillation: Post Hoc Analysis of the ELAN Randomized Clinical Trial. JAMA Neurol 2024; 81:693-702. [PMID: 38805207 PMCID: PMC11134281 DOI: 10.1001/jamaneurol.2024.1450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/08/2024] [Indexed: 05/29/2024]
Abstract
Importance Whether infarct size modifies the treatment effect of early vs late direct oral anticoagulant (DOAC) initiation in people with ischemic stroke and atrial fibrillation is unknown. Objective To assess whether infarct size modifies the safety and efficacy of early vs late DOAC initiation. Design, Setting, and Participants Post hoc analysis of participants from the multinational (>100 sites in 15 countries) randomized clinical Early Versus Later Anticoagulation for Stroke With Atrial Fibrillation (ELAN) trial who had (1) acute ischemic stroke, (2) atrial fibrillation, and (3) brain imaging available before randomization. The ELAN trial was conducted between October 2017 and December 2022. Data were analyzed from October to December 2023 for this post hoc analysis. Intervention Early vs late DOAC initiation after ischemic stroke. Early DOAC initiation was within 48 hours for minor or moderate stroke or on days 6 to 7 for major stroke; late DOAC initiation was on days 3 to 4 for minor stroke, days 6 to 7 for moderate stroke, and days 12 to 14 for major stroke. Main Outcomes and Measures The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, extracranial bleeding, systemic embolism, or vascular death within 30 days. The outcome was assessed according to infarct size (minor, moderate, or major) using odds ratios and risk differences between treatment arms. Interrater reliability for infarct size between the core laboratory and local raters was assessed, and whether this modified the estimated treatment effects was also examined. Results A total of 1962 of the original 2013 participants (909 [46.3%] female; median [IQR] age, 77 [70-84] years) were included. The primary outcome occurred in 10 of 371 participants (2.7%) with early DOAC initiation vs 11 of 364 (3.0%) with late DOAC initiation among those with minor stroke (odds ratio [OR], 0.89; 95% CI, 0.38-2.10); in 11 of 388 (2.8%) with early DOAC initiation vs 14 of 392 (3.6%) with late DOAC initiation among those with moderate stroke (OR, 0.80; 95% CI, 0.35-1.74); and in 8 of 219 (3.7%) with early DOAC initiation vs 16 of 228 (7.0%) with late DOAC initiation among those with major stroke (OR, 0.52; 95% CI, 0.21-1.18). The 95% CI for the estimated risk difference of the primary outcome in early anticoagulation was -2.78% to 2.12% for minor stroke, -3.23% to 1.76% for moderate stroke, and -7.49% to 0.81% for major stroke. There was no significant treatment interaction for the primary outcome. For infarct size, interrater reliability was moderate (κ = 0.675; 95% CI, 0.647-0.702) for local vs core laboratory raters and strong (κ = 0.875; 95% CI, 0.855-0.894) between core laboratory raters. Conclusions and Relevance The treatment effect of early DOAC initiation did not differ in people with minor, moderate, or major stroke assessed by brain imaging. Early treatment was not associated with a higher rate of adverse events, especially symptomatic intracranial hemorrhage, for any infarct size, including major stroke. Trial Registration ClinicalTrials.gov Identifier: NCT03148457.
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Affiliation(s)
- Martina B. Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Stefanie Abend
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Kneihsl
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Waldo Valenzuela Pinilla
- Support Center for Advanced Neuroimaging, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sabine Fenzl
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beata Rezny-Kasprzak
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roman Rohner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maurizio Paciaroni
- Internal, Vascular, and Emergency Medicine, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Patrik Michel
- Department of Neurology, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Leo Bonati
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal
- Faculty of Medicine, Institute of Anatomy, University of Lisbon, Lisbon, Portugal
| | - P. N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Zuzana Gdovinova
- Department of Neurology, Pavol Jozef Šafárik University, Košice, Slovakia
- Faculty of Medicine, Louis Pasteur University Hospital, Košice, Slovakia
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Kelly
- Stroke Clinical Trials Network Ireland, School of Medicine, University College Dublin and Department of Neurology, Mater University Hospital, Dublin, Ireland
| | - Mira Katan
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, United Kingdom
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University of Basel and University Hospital Basel, Basel, Switzerland
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