Decades ago, before the days of thrombolysis for ischemic stroke, many patients with acute ischemic stroke routinely received anticoagulation therapy. This practice is now less common, and the question is now when to start anticoagulation for long-term prevention of secondary stroke, particularly in patients with atrial fibrillation. When is the risk of a hemorrhagic complication of anticoagulation balanced by the beneficial effect of prevention of recurrent stroke? Early randomized trials focused on rapid anticoagulation with the use of heparin or low-molecular-weight heparin — agents that were associated with a risk of hemorrhage.1 In the past decade, observational studies of direct oral anticoagulants (DOACs) for persons with atrial fibrillation who have had an acute ischemic stroke started to explore the use of brain imaging and stroke severity to guide the decision regarding when to initiate treatment. Now, an international group of investigators has conducted a clinical trial to address this question, and Fischer et al.2 report the results in this issue of the Journal.
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