Anticoagulation safe to start before discharge

The latest updates to the Australian and New Zealand living stroke guidelines gives clarity around when people can start or restart anticoagulation medication after an ischaemic stroke.

Anticoagulant medications are used to prevent the blood clots that can lead to further strokes, particularly clots that can form in the heart due to atrial fibrillation.

Despite strong evidence for the use of these medications for long-term secondary prevention, the latest National Stroke Audit of Acute Services found that only 79% of ischaemic stroke patients were discharged with these medications. Often there is concern of an increased risk of bleeding, which can delay treatment.

However, a new, major randomised trial called ELAN (Early Versus Late Initiation of Direct Oral Anticoagulants in Post-ischaemic Stroke Patients With Atrial fibrillation) found that direct oral anticoagulation was safe within 48 hours of mild to moderate stroke, and from day 6–7 after a major stroke. Starting the medication at these times also reduced the risk of further strokes compared to starting later.

Based on this new research, members of the living stroke guidelines' Content Development Group agreed on a new conditional/weak recommendation to commence or recommence anticoagulation within these time frames.

The update was then approved by the National Health and Medical Research Council (NHMRC) on 8 December 2023, following public consultation earlier this year.

The Clinical Guidelines for Stroke Management continue to follow a living evidence approach, where monthly searches for new research evidence feed into 6-monthly reviews and updates where appropriate.

For further updates, we suggest you regularly check our Living guidelines updates.