Aristeidis H. Katsanos, MD, PhD

Groot AE, Vermeij J-DM, Westendorp WF, Nederkoorn PJ, van de Beek D, Coutinho JM. Continuation or Discontinuation of Anticoagulation in the Early Phase After Acute Ischemic Stroke. Stroke. 2018

Stroke clinicians frequently are confronted with the dilemma of not only weighting the thrombembolic risk to the risk of bleeding in acute ischemic stroke (AIS) patients with indication for anticoagulation, but they should also decide the optimal timing for anticoagulation resumption. Even though numerous studies have investigated so far the optimal timing of anticoagulation resumption in AIS patients, no study has directly compared anticoagulant continuation (without cessation) to discontinuation in patients suffering an AIS while on anticoagulation.

In this very interesting article, the authors present a post-hoc analysis from the Preventive Antibiotics in Stroke Study of 192 AIS patients who had a positive history for anticoagulation intake at admission. Anticoagulant discontinuation was decided by the treating physician in 18% of patients, and mostly in patients with increased stroke severity [median National Institutes of Health Stroke Scale (NIHSS) score of 13], while in the remaining cases of milder stroke severity (median NIHSS of 4) anticoagulation was continued without any interruption. In unadjusted analyses, patients in the discontinuation group were found to experience higher rates of thrombotic events, higher 3-month mortality rates and less favorable 3-month functional outcomes compared to patients with no anticoagulant interruption. However, after adjustment for potential confounders, there were no longer statistically significant differences between groups. Interestingly, no major bleeding events were reported in either group.

This analysis provides the first direct evidence that stroke clinicians seem to favor uninterrupted anticoagulant continuation in patients with mild AIS and history of anticoagulation intake on admission, in spite of current recommendations, which suggest anticoagulant cessation for a few days even for mild events. Moreover, the results of the present analysis also suggest that uninterrupted anticoagulant continuation is not associated with increased risk of major bleeding, an observation that requires validation within the settings of an adequately powered randomized clinical trial.