Table 2

Current guidelines on anticoagulation initiation timing after ischaemic stroke

GuidelineDateSummary of recommendationsReference
Royal College of Physicians, UK2016Defer anticoagulation for at least 14 days in disabling stroke; defer by no more than 14 days in non-disabling stroke. 70
Canadian Stroke Best Practice Recommendations2017Optimal timing to start anticoagulant therapy after stroke not defined by clinical trials; consider age, infarct size, imaging appearances, comorbidities and recurrence risk; suggests use of ESC 2016 ‘1-3-6-12’ guideline. 71
European Heart Rhythm Association2018Substantial study data regarding timing of initiation are missing. Present recommendations based on consensus opinion. Suggests use of ESC 2016 ‘1-3-6-12’ guideline. 72
CHEST2018Oral anticoagulation should usually be started within 2 weeks. The optimal timing within this period is not known. Infarct size is predictive of early recurrence, haemorrhagic transformation, and poor outcome, so might not be helpful in determining the net benefit of early treatment. 48
American Heart Association/American Stroke Association2019Reasonable to initiate anticoagulation between 4 and 14 days after onset in most patients with an AIS in the setting of AF. 73
European Stroke Organisation2019No recommendation based on randomised trials possible. Inclusion of patients in ongoing randomised trials of early anticoagulation encouraged. 11
European Society of Cardiology/EACTS2020Robust data to inform optimal timing are lacking. Initiate as soon as considered possible from neurological perspective. Whereas infarct size/stroke severity is used clinically to guide timing of OAC initiation, the usefulness of such an approach in estimating the net benefit of early treatment may be limited. 49
  • AF, atrial fibrillation; AIS, Acute ischaemic stroke; ESC, European Society of Cardiology; OAC, oral anticoagulants.