Methodology: 3/5
Usefulness: 2/5

Fischer U, et al. N Engl J Med. 2023 Jun 29;388(26):2411-2421. 

Question and Methods: RCT at 103 sites to compare outcomes at 30 days for early versus late DOAC initiation among patients with ischemic stroke and atrial fibrillation.
Findings: Primary outcome (ischemic stroke, systemic embolism, major bleeding, vascular death) occurred in 2.9% (Early) vs 4.1% (late) [risk difference -1.18, 95% CI, -2.87 to 0.47].
Limitations: Stroke severity defined by infarct size on imaging the composite outcome included both the benefits and the side effects of the treatment; and study did not have a hypothesis. Overall this study trended occurrences of events without hypothesis, thus making drawing a conclusion from the results difficult.

Interpretation: There seems to be a signal towards being able to start anticoagulation earlier, as is in line with Canadian Stroke Best Practices. Although NNT is quite high, and the applicability of this study to the ED setting is limited.

by: Dr. Josee Malette

JC Supervisor: Dr. Venkatesh Thiruganasambandamoorthy




  • Josee Malette

    Dr. Josée Malette is an Emergency Medicine Resident in the Department of Emergency Medicine, University of Ottawa. She is a Senior Editor with the Digital Scholarship and Knowledge Dissemination team for the EMOttawaBlog. Her interests involve critical care in low resource settings, medical education, rural medicine and prehospital medicine.

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  • Hans Rosenberg

    Dr. Rosenberg is an emergency physician at the Ottawa Hospital, associate professor at the University of Ottawa, and Director of the Digital Scholarship and Knowledge Dissemination Program.

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  • Venkatesh Thiruganasambandamoorthy

    Dr. Venkatesh Thiruganasambandamoorthy is an attending physician and associate scientist at the Ottawa Hospital and Ottawa Hospital Research Institute with an particular interest in syncope and presyncope care.

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