# Early versus delayed DOAC after ischaemic stroke in atrial fibrillation: 1-year outcomes in the TIMING study and in concurrent practice

## TL;DR

This study compares early versus delayed use of blood thinners after stroke in patients with heart rhythm issues, finding early use is safe and effective.

## Contribution

The study provides new evidence on the long-term safety and effectiveness of early DOAC initiation after stroke in atrial fibrillation patients.

## Key findings

- Early DOAC initiation showed no increased risk of bleeding after one year.
- Observational data showed better outcomes with early DOAC initiation.
- Adjusted hazard ratios indicated a lower risk in the early group.

## Abstract

A recent meta-analysis, including the TIMING study, found favourable short-term outcomes after early initiation of a direct-acting oral anticoagulant (DOAC), as compared to delayed initiation, following acute ischaemic stroke in patients with atrial fibrillation. We aimed to investigate 1-year outcomes after early vs delayed DOAC initiation in the TIMING study population and a concurrent observational cohort.

In TIMING, adults with atrial fibrillation were randomised to initiation of DOAC either within 4 days or at 5–10 days after acute ischaemic stroke. The non-randomised cohort comprised patients with acute ischaemic stroke and atrial fibrillation, observed in the Swedish Stroke Register concurrently with the TIMING study and initiating DOAC within 4 or 5–10 days, respectively. Outcomes in both populations were acute ischaemic stroke, symptomatic intracerebral haemorrhage or death, as a composite and individually, analysed using Cox regression models, with adjustment for risk factors in the observational cohort.

In the TIMING population (n = 888), the composite outcome at 365 days occurred in 64/450 patients (14.2%) with early DOAC initiation and 66/438 (15.1%) with delayed, unadjusted hazard ratio 0.92 (95% CI, 0.66–1.30). In the observational cohort (n = 8951), the composite outcome at 365 days occurred in 1227/6671 (18.4%) patients initiating DOAC early and 511/2280 (22.4%) in the delayed group, adjusted hazard ratio 0.80 (0.69–0.91).

At 1-year follow-up, early initiation of DOAC remained safe and effective with no increase in symptomatic intracerebral haemorrhage. The results support early DOAC initiation in patients with acute ischaemic stroke and atrial fibrillation.

Graphical Abstract