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When to start direct oral anticoagulants after clot removal for stroke with atrial fibrillation

Timing of Anticoagulation After Emergency Endovascular Therapy for Acute Ischemic Stroke With Atrial Fibrillation: a Randomised Controlled Trial

Not applicable Interventional Capital Medical University · NCT07139314

This will test whether starting direct oral anticoagulants early versus waiting after emergency clot removal is safer and better at preventing new strokes for people with atrial fibrillation who show bleeding changes on imaging.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment240 (estimated)
Ages18 Years and up
SexAll
SponsorCapital Medical University Academic / other
Locations37 sites (Ma’anshan, Anhui and 36 other locations)
Trial IDNCT07139314 on ClinicalTrials.gov

What this trial studies

This is a multicenter, prospective, open-label randomized trial comparing early versus delayed initiation of direct oral anticoagulants (DOACs) in adults with atrial fibrillation who had large-vessel ischemic stroke treated by emergency endovascular therapy and then developed hemorrhagic transformation on CT or MRI. Eligible patients are enrolled after EVT (within 24 hours of stroke onset) and randomized to a prespecified early or delayed DOAC start, with imaging-based classification of hemorrhagic transformation using the Heidelberg criteria. The trial captures safety outcomes such as symptomatic intracranial hemorrhage and efficacy outcomes including recurrent ischemic events and functional status at 90 days. Results aim to provide practical timing guidance for restarting anticoagulation in this high-risk post‑EVT population.

Who should consider this trial

Good fit: Adults (≥18) with large-vessel occlusion ischemic stroke treated with emergency endovascular therapy within 24 hours who have atrial fibrillation and imaging-confirmed hemorrhagic transformation meeting the trial's Heidelberg-based criteria.

Not a fit: People with extensive parenchymal hematoma with major mass effect, clear contraindications to anticoagulation, or strokes not related to atrial fibrillation are unlikely to benefit from this trial's interventions.

Why it matters

Potential benefit: If successful, the results could reduce recurrent strokes while minimizing bleeding by giving clear, evidence-based timing for restarting DOACs after EVT-related hemorrhagic changes.

How similar studies have performed: Some recent randomized and observational studies (for example ELAN and cohort analyses) have supported earlier DOAC starts after ischemic stroke generally, but timing specifically after hemorrhagic transformation following EVT remains relatively untested.

Eligibility criteria

Show full inclusion / exclusion criteria 
Inclusion Criteria:

1. Aged 18 years or over.
2. Clinical diagnosis of large vessel occlusion acute ischemic stroke.
3. Emergency endovascular treatment was performed within 24 hours of stroke onset.
4. Atrial fibrillation (including paroxysmal, persistent or permanent atrial fibrillation), confirmed by at least one of the following:

   1. 12-lead ECG recording;
   2. Inpatient ECG telemetry;
   3. Prolonged ECG monitoring (e.g. Holter monitor);
   4. Previously established diagnosis of atrial fibrillation verified by medical records.
5. CT or MRI demonstrating one of the following findings:

   1. Parenchymatous hematoma type 1: defined as hematoma occupying less than 30% of the infarcted tissue, no substantive mass effect (Heidelberg classification);
   2. Parenchymatous hematoma type 2: defined as heamtoma occupying 30% or more of the infarcted tissue, with obvious mass effect (Heidelberg classification);
   3. Intracerebral hemorrhage outside the infarcted brain tissue or intracranial-extracerebral hemorrhage (Heidelberg classification).
6. Time from stroke onset to randomization ranged from 7 days to 4 weeks.
7. Written informed consent obtained from the patient or a legally authorized representative.

Exclusion Criteria:

1. Atrial fibrillation due to reversible causes (e.g. thyrotoxicosis, pericarditis, recent surgery, or myocardial infarct).
2. Contraindication to the use of direct oral anticoagulants (DOACs):

   1. Known allergy or intolerance to both factor Xa inhibitors and direct thrombin inhibitors;
   2. Definite indication for vitamin K antagonist (VKA) treatment (e.g. mechanical heart valve, valvular atrial fibrillation);
   3. Severe renal impairment (defined as creatinine exceeding 1.5 times of the upper limit of normal range) and significant hepatic dysfunction (defined as ALT or AST \> twice the upper limit of normal range) ;
   4. Concomitant use of medications with significant interactions with DOACs, including azole antifungals, HIV protease inhibitors, or strong CYP3A4 inducers;
   5. Baseline platelet count \< 100 x 109/L;
   6. History of coagulopathy or systemic hemorrhage.
3. Prior DOAC use within 48 hours of stroke onset, or recent treatment with vitamin K antagonist (VKA) leading to INR ≥1.7 at randomization.
4. Pregnant or breastfeeding women, or positive pregnancy test at admission.
5. History of major surgery or severe trauma within 1 month prior to stroke onset.
6. History of active bleeding within 1 month prior to stroke onset (e.g. gastrointestinal bleeding, urinary tract bleeding).
7. Dual antiplatelet therapy at baseline, or strong likelihood of requiring dual antiplatelet therapy during the trial.
8. Evidence of cerebral amyloid angiopathy.
9. CT or MRI evidence of non-stroke pathology likely to account for the presenting clinical symptoms (e.g. mass lesion, encephalitis).
10. Modified Rankin scale (mRS) score \> 1 prior to stroke onset.
11. Inability to complete the 90-day follow-up.
12. Currently participating in another drug clinical trial.
13. Any other reason deemed by the investigator to make the patient unsuitable for participation in the trial.

Where this trial is running

Ma’anshan, Anhui and 36 other locations

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
View on ClinicalTrials.gov → Find more trials like this →
Conditions Ischemic StrokeAtrial FibrillationEndovascular therapyDirect oral anticoagulationTherapy initiationHemorrhagic transformationRandomized Controlled TrialStroke
Last reviewed 2026-06-13 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.