Authors: 
Dr. Räty Silja
Optimal strategy of anticoagulation for patients with either ischaemic or haemorrhagic stroke and atrial fibrillation (AF) has been a hot topic in stroke research within the past few years. The accumulating evidence to guide treatment of these patients was summed up in the latest ESO educational webinar on 25 March by speakers Dr. Maria Gabriel from Germany and Prof. Georgios Tsivgoulis from Greece. The event was hosted by Dr. van Etten and Dr. Peycheva.
What is the optimal timing to initiate anticoagulation in patients with ischaemic stroke and AF to prevent stroke recurrence and to avoid clinical deterioration caused by haemorrhagic transformation? And is it possible to restart anticoagulation after spontaneous intracerebral haemorrhage (ICH) or does ICH recurrence exceed the benefits of reducing the risk of thromboembolism? These questions were highlighted in clinical cases presented by Dr. Gabriel.
The case presentations were followed by a talk from Prof. Tsivgoulis who reviewed pivotal studies on anticoagulation in stroke patients. AF is a common finding not only after embolic stroke but also in patients with small-vessel disease, large-artery atherosclerosis, or cryptogenic stroke. Guidelines give a IA level recommendation for direct oral anticoagulants (DOAC) over warfarin for patients with AF and increased thromboembolic risk due to better efficacy and superior safety profile, despite a higher risk of gastrointestinal bleeding.
The guidelines become vaguer when it comes to timing of anticoagulation for AF after stroke. Fortunately, new evidence has emerged from four randomised controlled trials (RCT) that compared early versus late anticoagulation after ischaemic stroke. Although the design and selection criteria of the trials differ, they have consistently shown non-inferiority of early initiation. Furthermore, Prof. Tsivgoulis discussed the results of the Catalyst individual-patient data meta-analysis that was presented in the World Stroke Congress in 2024. The meta-analysis was the first to prove superiority of early anticoagulation (≤ 4 days) in preventing recurrent ischaemic strokes without increasing haemorrhagic complications.1 However, caution should be applied to patients with parenchymal haemorrhagic transformation, as pointed out by Prof. Tsivgoulis.
The second critical question on anticoagulation, whether to restart after ICH, has also been investigated in several RCTs, including the recently published PRESTIGE-AF.1 So far, the trials have not been able to provide a definitive answer to this question. Restarting seems to decrease the risk of ischaemic stroke but at the cost of a higher incidence of recurrent ICH. Therefore, the current guidelines suggest individual approach weighing thromboembolic and bleeding risks with particular attention to the location of the hematoma. However, there are still several ongoing trials on the topic, which may aide the clinician in the future.
1. Veltkamp R, Korompoki E, Harvey KH, et al. Direct oral anticoagulants versus no anticoagulation for the prevention of stroke in survivors of intracerebral haemorrhage with atrial fibrillation (PRESTIGE-AF): a multicentre, open-label, randomised, phase 3 trial. Lancet 2025; 405: 927–936.
Missed the webinar? Education webinars are available on demand for ESO members on the ESO eSTEP platform.
Not a member yet? Sign up now.
ESOC is Europe’s leading forum for advances in research and clinical care of patients with cerebrovascular diseases. ESOC 2025 will live up to its expectation, and present to you a packed, high quality scientific programme including major clinical trials, state-of-the-art seminars, educational workshops, scientific communications of the latest research, and debates about current controversies. Learn more.
