Outcomes of Early Versus Later Anticoagulation in Asian Atrial Fibrillation–Related Stroke: ELAN Subgroup Analysis

Background and Purpose We aimed to evaluate whether early versus late initiation of direct oral anticoagulant (DOAC) after acute ischemic stroke (AIS) yields different safety and efficacy outcomes in Asian versus non-Asian patients.Methods We analyzed Early versus Late initiation of direct oral Anticoagulants in post-ischaemic stroke patients with atrial fibrillatioN (ELAN) trial data from 2,013 AIS patients with atrial fibrillation (AF) randomized to early (≤48 hours for minor/moderate stroke, 6–7 days for major stroke) or late DOAC initiation (3–4 days for minor ischemic stroke, 6–7 days for moderate ischemic stroke, 12–14 days for major ischemic stroke). Patients were categorized by region as Asian (Japan and India) or non-Asian. The primary outcome was a composite of major extracranial bleeding, symptomatic uncerintracranial hemorrhage (SICH), recurrent ischemic stroke, systemic embolism (SE), or vascular death at 30 days (trial registration: ClinicalTrials.gov number, NCT03148457).Results Among 1,975 patients, 245 were Asian (192 from Japan and 53 from India) and 1,730 were non-Asian. The primary outcome occurred in 6.5% of Asian patients (4.8% early vs. 8.3% late) and 3.1% of non-Asian patients (2.7% vs. 3.6%) (<i>p</i><0.01). Higher rates of recurrent ischemic stroke (4.1% [2.4% vs. 5.8%] vs. 1.7% [1.3% vs. 2.1%], <i>p</i>=0.02) and SE (2.0% [0.8% vs. 3.3%] vs. 0.5% [0.4% vs. 0.6%], <i>p</i>=0.02) accounted for this difference. No significant differences were observed in major extracranial bleeding, SICH, recurrent ischemic stroke, SE, or vascular death. No significant interaction was observed between region and treatment allocation.Conclusions Although Asian patients had worse baseline profiles and outcomes, treatment effects did not differ by region, supporting the generalizability of early DOAC initiation in Asian AIS patients without region-specific timing modifications.

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Journal
Journal of Stroke
Published
2026-05-29
DOI
https://doi.org/10.5853/jos.2025.05848
Primary Topic
Acute Ischemic Stroke Management
Type
article
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article

Outcomes of Early Versus Later Anticoagulation in Asian Atrial Fibrillation–Related Stroke: ELAN Subgroup Analysis

Ana Paiva Nunes, Vijaya Pamidimukkala, Jean‐Benoît Rossel, Hisanao Akiyama et al.
Journal of Stroke
Acute Ischemic Stroke Management
article

Outcomes of Early Versus Later Anticoagulation in Asian Atrial Fibrillation–Related Stroke: ELAN Subgroup Analysis

Ana Paiva Nunes, Vijaya Pamidimukkala, Jean‐Benoît Rossel, Hisanao Akiyama, Thomas Iype, Rajsrinivas Parthasarthy, Dheeraj Khurana, Jeyaraj Durai Pandian, V Nambiar, Dimitri Hemelsoet, Caterina Kulyk, Yusuke Yakushiji, Shigeru Fujimoto, Sven Poli, Nicoletta G. Caracciolo, Urs Fischer, Yasuyuki Iguchi, Masatoshi Koga, Jesse Dawson, P N Sylaja, Makoto Nakajima, Kazunori Toyoda, Masafumi Ihara, Angelika Alonso, Takeshi Yoshimoto
article en

Abstract

Background and Purpose We aimed to evaluate whether early versus late initiation of direct oral anticoagulant (DOAC) after acute ischemic stroke (AIS) yields different safety and efficacy outcomes in Asian versus non-Asian patients.Methods We analyzed Early versus Late initiation of direct oral Anticoagulants in post-ischaemic stroke patients with atrial fibrillatioN (ELAN) trial data from 2,013 AIS patients with atrial fibrillation (AF) randomized to early (≤48 hours for minor/moderate stroke, 6–7 days for major stroke) or late DOAC initiation (3–4 days for minor ischemic stroke, 6–7 days for moderate ischemic stroke, 12–14 days for major ischemic stroke). Patients were categorized by region as Asian (Japan and India) or non-Asian. The primary outcome was a composite of major extracranial bleeding, symptomatic uncerintracranial hemorrhage (SICH), recurrent ischemic stroke, systemic embolism (SE), or vascular death at 30 days (trial registration: ClinicalTrials.gov number, NCT03148457).Results Among 1,975 patients, 245 were Asian (192 from Japan and 53 from India) and 1,730 were non-Asian. The primary outcome occurred in 6.5% of Asian patients (4.8% early vs. 8.3% late) and 3.1% of non-Asian patients (2.7% vs. 3.6%) (<i>p</i><0.01). Higher rates of recurrent ischemic stroke (4.1% [2.4% vs. 5.8%] vs. 1.7% [1.3% vs. 2.1%], <i>p</i>=0.02) and SE (2.0% [0.8% vs. 3.3%] vs. 0.5% [0.4% vs. 0.6%], <i>p</i>=0.02) accounted for this difference. No significant differences were observed in major extracranial bleeding, SICH, recurrent ischemic stroke, SE, or vascular death. No significant interaction was observed between region and treatment allocation.Conclusions Although Asian patients had worse baseline profiles and outcomes, treatment effects did not differ by region, supporting the generalizability of early DOAC initiation in Asian AIS patients without region-specific timing modifications.

Journal of StrokeVol. 28(2)
Jikei University School of Medicine (JP), University of Bern (CH), Johannes Kepler University of Linz (AT), Kansai Medical University (JP), Amrita Institute of Medical Sciences and Research Centre (IN), Government Medical College (IN), Jichi Medical University (JP), St. Marianna University School of Medicine (JP), University of Lucknow (IN), Heidelberg University (DE), Policlinico Umberto I (IT), Sree Chitra Thirunal Institute for Medical Sciences and Technology (IN), University Hospital of Bern (CH), Ghent University Hospital (BE), University Hospital Heidelberg (DE), Max Super Speciality Hospital (IN), Unidade Local de Saúde de São José (PT), Hiroshima City Asa Citizens Hospital (JP), National Cerebral and Cardiovascular Center (JP), University of Tsukuba Hospital (JP), Hertie Institute for Clinical Brain Research (DE), University Medical Centre Mannheim (DE), Post Graduate Institute of Medical Education and Research (IN), University of Glasgow (GB), University of Tübingen (DE), Kumamoto University (JP)
National Science Foundation, Amgen, Eli Lilly and Company, Pfizer, AstraZeneca, Sanofi, Biogen, Alexion Pharmaceuticals, CSL Behring, Boston Scientific Corporation, Stryker, University of Bern, Schweizerischen Neurologischen Gesellschaft, Amicus Therapeutics, Kowa Company, Japan Blood Products Organization, National Cerebral and Cardiovascular Center, Boehringer Ingelheim Japan, European Commission, Bayer HealthCare, Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung, Bundesministerium für Bildung und Forschung, Universitair Ziekenhuis Gent, Eisai, Schweizerische Herzstiftung, Universiteit Gent, Otsuka Pharmaceutical, Schweizerische Akademie der Medizinischen Wissenschaften, Pfizer Japan, Bayer Yakuhin
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Acute Ischemic Stroke Management
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