What is the optimal timing for initiating oral anticoagulation in patients with stroke or TIA in the setting of AF?
The optimal timing of initiating oral anticoagulation should be individualized for each patient’s risk of hemorrhage versus recurrent embolism. An analysis of the VISTA cohort study (Virtual International Stroke Trials Archive) of 1644 patients found fewer recurrent strokes with initiation of VKA 2 to 3 days after stroke compared with >3 days without increased risk of symptomatic hemorrhage. In patients with larger cerebral infarcts, evidence of hemorrhage on neuroimaging, NIHSS score >9, or other features that place them at increased risk of hemorrhagic conversion after acute stroke, the balance of risk and benefit favors waiting for healing and reduced bleeding risk.