Stroke patients could benefit from earlier blood thinning treatment

Treating patients earlier after a stroke has been shown to safely help prevent a second stroke.

Patients with atrial fibrillation (AF) are five times more likely to have a stroke than the general population. If they do have a stroke, they are at high risk of having another.

This risk can be reduced by taking blood thinning medications called anticoagulants. However, these can sometimes cause bleeding in the brain, so it is important to get the timing right.

Now, results from the OPTIMAS study show it is safe and effective to give patients with this condition anticoagulants in the first few days after a stroke.

University Hospital Southampton (UHS) was one of 100 UK hospitals, with 42 patients taking part.

Striking a ‘delicate balance’

More than 1.6 million people in the UK have been diagnosed with AF. People with AF have an irregular heartbeat, which can lead to a clot forming inside the heart. This clot can travel to the brain, blocking its blood supply and causing a stroke.

Giving anticoagulants to these patients can help prevent a second stroke. However, these come with a rare but dangerous potential side effect of bleeding in the brain.

To reduce the risk of this side effect, some current UK guidelines recommend waiting at least five days after a stroke before starting treatment. However, there was little evidence to support this.

The OPTIMAS study aimed to find out if giving anticoagulants earlier was safe. It was led by Professor David Werring, Professor of Clinical Neurology at University College London.

He said: “For many years, there has been a dilemma over the optimal time to start anticoagulants in people with a stroke and atrial fibrillation.

“Doctors typically recommend waiting up to two weeks out of fear that earlier treatment might cause bleeding into the brain. But during this time patients remain at risk of another stroke due to a further blood clot from the heart.”

The study was funded by the British Heart Foundation.

Providing new evidence

Overall, more than 3,000 patients with AF took part after having a stroke. Half started anticoagulant treatment within four days of their stroke (early), and the other half at 7-14 days (delayed). After 90 days, the researchers checked if patients had experienced another stroke or bleeding in the brain.

They found early treatment was effective and did not increase the risk of a bleed in the brain. Both groups had a similar number of recurrent strokes.

Professor Werring said: “The OPTIMAS trial clearly shows that starting an anticoagulant early does not increase the risk of bleeding into the brain, even in patients with more severe strokes.

“We now plan to combine OPTIMAS data with that from other trials to determine whether offering anticoagulation sooner can prevent early stroke recurrence.”

Aiming to change practice

The researchers hope these results will now lead to a change in how these patients are treated. They say this could benefit up to 20,000 patients in the UK each year.

Professor Werring said: “This important study reveals that taking blood thinning medication within the first few days of a stroke does not come with heightened risk, as previously thought.”

“These results could be transformative, making the case for earlier treatment that could help more people with atrial fibrillation avoid having another stroke, and the associated complications.”

Dr Richard Marigold, Consultant in Stroke Medicine at UHS, led the recruitment of patients in Southampton. He is supported by the UHS Research Leaders Programme.

He said: “These results provide important safety data showing no increased risk of haemorrhage by starting anticoagulation earlier. This means we can now translate this into clinical practice by starting direct oral anticoagulants that much sooner.”