Apostolos Safouris, MD, PhD, Athens Metropolitan Hospital, Athens, Greece, shares an overview of the current evidence base regarding initiation of anticoagulation medication after reperfusion therapy for ischemic stroke. Given the high risk of stroke recurrence in the days after the initial event, as well as the increased risk of hemorrhagic stroke in the early time period, controversy remains about the optimal time to initiate anticoagulation that is the best balance of safe and effective. Dr Safouris comments on some of the key studies that have helped to inform decision making, including the RAF-NOACs observational study (increased bleeding risk when DOACs initiated within 2 days), MR CLEAN-MED (periprocedural heparin associated with unacceptable bleeding risk), Triple AXEL (warfarin and rivaroxaban comparably safe and effective when initiated within 5 days after mild stroke), and RELAXED (rivaroxaban may be feasible within 3 days of onset for small-medium infarctions). A lack of randomized data makes it difficult to draw conclusions, especially in individuals with severe strokes or early hemorhagic transformation. Most data converges on the fact that patients should receive anticoagulation within the first two weeks, with the timing dependent on infarct severity and the presence of hemorrhagic transformation. This interview took place during the European Stroke Organisation Conference (ESOC) in Munich, Germany.
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