OPTIMAS: OPtimal TIMing of Anticoagulation After Acute Ischaemic Stroke : a Randomised Controlled Trial

Study Overview
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Brief Summary
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OPTIMAS is a large, prospective, partially blinded randomised controlled trial of early (within ≤4 days [96hrs]) or standard (between day 7 and day 14 after stroke onset) initiation of anticoagulation after stroke in patients with atrial fibrillation (AF), using any licensed dose of a direct oral anticoagulant (DOAC). The trial will use a non-inferiority gatekeeper approach to test for non-inferiority of early anticoagulation followed by a test for superiority, if non-inferiority is established.

Detailed Description
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Current guidelines do not provide clear recommendations on the timing of OAC after acute AF-related stroke. Current United Kingdom (UK) guidelines for anticoagulation state that delay for an arbitrary 2-week period is recommended for disabling stroke and that anticoagulation can be started no later than 14 days for other strokes, at the prescriber's discretion. OPTIMAS will investigate whether early initiation of DOAC treatment, within 4 days (96hrs) of onset, in patients with acute ischaemic stroke and AF is as effective as, or better than, standard initiation of DOAC treatment, no sooner than day 7 (>144hrs) and no later than day 14 (<336hrs) after onset, in preventing recurrent ischaemic stroke, systemic embolism and symptomatic intracranial haemorrhage (sICH)? Participants will be randomised 1:1 to the intervention or control. The exact timing of initiating treatment within each group is at the discretion of the treating clinician.

Official Title
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OPtimal TIMing of Anticoagulation After Acute Ischaemic Stroke: a Randomised Controlled Trial

Conditions
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Stroke, Acute, Atrial Fibrillation

Intervention / Treatment
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* Drug: Direct oral anticoagulant (DOAC)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged 18 years or over Clinical diagnosis of acute ischaemic stroke AF, confirmed by any of: 12-lead ECG recording Inpatient ECG telemetry Other prolonged ECG monitoring technique (e.g. Holter monitor) Known diagnosis of atrial fibrillation verified by medical records (e.g. primary care records, letter from secondary care) Eligibility to commence DOAC in accordance with approved prescribing recommendations confirmed by treating physician Uncertainty on the part of the treating physician regarding early versus standard initiation of DOAC. Exclusion Criteria: Contraindication to anticoagulation: Coagulopathy or current or recent anticoagulation with vitamin K antagonist (VKA) leading to INR ≥1.7 at randomisation. Thrombocytopenia (platelets < 75 x 10⁹/L) Other coagulopathy or bleeding tendency (based on clinical history or laboratory parameters) judged to contraindicate anticoagulation by treating clinician Contraindication to early anticoagulation Known presence of haemorrhagic transformation with parenchymal haematoma occupying >30% of the infarct volume and exerting significant mass effect (i.e. PH2) (NB: HI1, HI2 and PH1 are not considered contraindications) Presence of clinically significant intracranial haemorrhage unrelated to qualifying infarct Any other contraindication to early anticoagulation as judged by the treating clinician Contraindication to use of DOAC: Known allergy or intolerance to both Factor Xa inhibitor and direct thrombin inhibitor Definite indication for VKA treatment e.g. mechanical heart valve, valvular AF, antiphospholipid syndrome Severe renal impairment with creatinine clearance (Cockcroft & Gault formula) <15 mL/min (i.e. 14 mL/min or less) Liver function tests ALT > 2x ULN Cirrhotic patients with Child Pugh score equating to grade B or C Patient is taking medication with significant interaction with DOAC, including: Azole antifungals (e.g. ketoconazole, itraconazole) HIV protease inhibitors (e.g. ritonavir) Strong CYP3A4 inducers (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital or St. John's Wort) Dronedarone Pregnant or breastfeeding women Presence on acute brain imaging of non-stroke pathology judged likely to explain clinical presentation (e.g. mass lesion, encephalitis) Inability for patient to be followed up within 90 days of trial entry Patient or representative refusal to consent to study procedures, including the site informing GP and healthcare professional responsible for anticoagulation care of participants Any other reason that the PI considers would make the patient unsuitable to enter OPTIMAS. Note that current DOAC treatment is NOT an exclusion criterion, as long as the treating physician considers it appropriate to restart (or continue) according to the timings specified in the OPTIMAS trial protocol. Continuation of the DOAC would be recorded as a start time of zero hours.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients will be randomised in a 1:1 ratio to intervention or control arms of the study. Participants and their physicians will not be blinded to study arm allocation.The exact timing of anticoagulation within the period specified for the allocated study arm is at the discretion of the treating physician, as is the choice of DOAC. Apart from the timing of DOAC initiation, the DOAC should be prescribed in accordance with usual clinical practice
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Early initiation of DOAC<br>Early initiation of any direct oral anticoagulant (DOAC) at a dose licensed for stroke prevention in AF, within four days (96hrs) of onset of acute ischaemic stroke | Drug: Direct oral anticoagulant (DOAC)<br>* Any of the DOACs listed above may be used for treatment in either study arm. The DOAC will be supplied from normal hospital stock, using local hospital prescriptions.<br>* Other names: dabigatran, apixaban, edoxaban, rivaroxaban;|
| Active Comparator: Standard Initiation of DOAC<br>Standard initiation of any DOAC at a dose licensed for stroke prevention in AF, no sooner than day 7 and no later than day 14 after the onset of acute ischaemic stroke (i.e. between 144hrs and 336hrs from onset). | Drug: Direct oral anticoagulant (DOAC)<br>* Any of the DOACs listed above may be used for treatment in either study arm. The DOAC will be supplied from normal hospital stock, using local hospital prescriptions.<br>* Other names: dabigatran, apixaban, edoxaban, rivaroxaban;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Composite outcome of the combined incidence of:recurrent symptomatic ischaemic stroke,symptomatic intracranial haemorrhage and systemic embolism | OPTIMAS will investigate whether early initiation of DOAC treatment in patients with acute ischaemic stroke and atrial fibrillation is as effective as, or better than, standard initiation of DOAC treatment in preventing recurrent ischaemic stroke, systemic embolism and sICH. | At 90 days from randomisation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All-cause mortality | All cause mortality reported in both arms | At 90 days from randomisation | 
| Incidence of vascular death | Any incidence of vascular death reported in both arms | At 90 days from randomisation | 
| Incidence of recurrent ischaemic stroke | Any incidence of recurrent ischaemic stroke reported in both arms | At 90 days from randomisation | 
| Incidence of systemic embolism | Any incidence of incidence of systemic embolism reported in both arms | At 90 days from randomisation | 
| Incidence of venous thromboembolism (deep vein thrombosis [DVT], pulmonary embolism [PE], cerebral venous thrombosis [CVT]) | Any of Incidence of venous thromboembolism (deep vein thrombosis [DVT], pulmonary embolism [PE], cerebral venous thrombosis [CVT]) reported in both arms | At 90 days from randomisation | 
| Functional status assessed by the modified Rankin scale (mRS) in both arms | The Modified Rankin Scale measures the degree of disability and dependence following a stroke. The scale consists of 7 category descriptions, where 0 means no symptoms, 1 means no significant disability, 2 means slight disability, 3 means moderate disability, 4 means moderately severe disability, 5 means severe disability and 6 means death. The assessment is carried out by asking the participant or their carer about their activities of daily living. | At 90 days from randomisation | 
| Cognitive ability assessed by the Montreal Cognitive Assessment (MoCA) questionnaire in both arms | The Montreal Cognitive Assessment is a questionnaire widely used as a screening assessment for detecting cognitive impairment. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. An abbreviated version of the MoCA assessing attention, verbal learning, memory, executive functions/language and orientation can be performed over the phone. MoCA scores range between 0 and 30. A score of 26 or over is considered to be normal. In a study and people with mild cognitive impairment (MCI) scored an average of 22.1. | At 90 days from randomisation | 
| Quality of life at 90 days assessed by EuroQol 5 Dimensions 5 level questionnaire [EQ-5D-5L] in both arms | The EQ-5D-5L includes 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. The EQ VAS records the respondent's self-rated health on a vertical, visual analogue scale where the endpoints are labelled 'Best imaginable health state' and 'Worst imaginable health state'. In instances in which the participant struggles with giving answers on their own, the participant's next-of-kin or a friend who knows the participant well will be asked to complete the EQ-5D-5L proxy version. The proxy is asked to rate how they think the participant would rate their own health-related quality of life, if the participant were able to communicate it. In case a proxy is not available, the research team member who was looking after the participant will complete it on their behalf. | At 90 days from randomisation | 
| Patient reported outcomes assessed by the Patient-Reported Outcomes Measurement Information System Global Health questionnaire (PROMIS-10) in both arms. | The PROMIS Global-10 short form consists of 10 items that assess general domains of health and functioning including overall physical health, mental health, social health, pain, fatigue, and overall perceived quality of life. The scoring system of the PROMIS Global-10 allows each of the individual items to be examined separately to provide specific information about perceptions of physical function, pain, fatigue, emotional distress, social health and general perceptions of health where 0 means never experienced this problem or symptoms and 1 means always. The higher score for each response indicate better health. | At 90 days from randomisation | 
| Ongoing anticoagulation | Ongoing anticoagulation will be assessed based on patient self-reporting and follow up patient medical records if necessary in both arms | At 90 days from randomisation | 
| Time to first incidence of primary outcome component (recurrent ischaemic stroke, systemic embolism, or sICH) | Time to first incidence of primary outcome component (recurrent ischaemic stroke, systemic embolism, or sICH) reported in both arms | At 90 days from randomisation | 
| Length of hospital stay for stroke-related care | Length of hospital stay for stroke-related care in both arms | At 90 days from randomisation | 
| Health and social care resource use | Health and social care resources (assessed by a study specific questionnaire) in both arms | At 90 days from randomisation | 
| Incidence of symptomatic intracranial haemorrhage (sICH) | Incidence of symptomatic intracranial haemorrhage (sICH) classified according to site intracerebral haemorrhage (within the brain parenchyma); subdural haemorrhage; extradural haemorrhage; subarachnoid haemorrhage; and haemorrhagic transformation of a brain infarct, in both arms | At 90 days from randomisation | 
| Incidence of major extracranial bleeding | Incidence of major extracranial bleeding reported in both arms | At 90 days from randomisation | 
| Incidence of all major bleeding (intracranial and extracranial) | Incidence of all major bleeding (intracranial and extracranial) reported during the study period, in both arms | At 90 days from randomisation | 
| Incidence of clinically relevant non-major bleeding | Incidence of clinically relevant non-major bleeding reported in both arms | At 90 days from randomisation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ischaemic stroke, atrial fibrilation