Timing of Initiating Oral Anticoagulant Administrations in Stroke Patient Who Developed Atrial Fibrillation: A Systematic Review and Meta-analysis
Muhnnad AlGhamdi1, Reem Almalki2, Maram Bukhari1, Maya Baselm1, Haneen Alshareef1, Rataj Alharbi3, Ahmed Alkhiri1, Alaa Maglan1, Alaa Heji1, Yasser Aladdin1, Seraj Makkawi4
1King Saud bin Abdulaziz University for Health Sciences, 2Umm Al-Qura University, 3Jeddah Uviversity, 4King Saud bin Abdulaziz University for Health Sciences - Jeddah
Objective:

This systematic review and meta-analysis aimed to evaluate existing evidence on the optimal timing of anticoagulation initiation after ischemic stroke in patients with atrial fibrillation (AF). The goal was to determine whether early or delayed initiation leads to better clinical outcomes by balancing the risk of recurrent ischemic stroke against hemorrhagic complications, providing evidence-based guidance for clinical decision-making.

Background:
Stroke is a leading global cause of disability and death, with AF markedly increasing stroke risk through embolic events. AF-related strokes are typically more severe and carry worse prognoses. While anticoagulation is essential for secondary prevention, the ideal timing for initiation remains uncertain. Early treatment may lower recurrence but increase hemorrhagic transformation risk, whereas delayed therapy may leave patients vulnerable to ischemic events. Current guidelines recommend anticoagulation but provide limited direction regarding timing.
Design/Methods:

Following PRISMA guidelines (PROSPERO ID: CRD420250630978), eligible studies included randomized controlled trials and observational or interventional studies on adults (>18 years) with ischemic stroke and non-valvular AF comparing early versus delayed oral anticoagulation (OAC). Databases searched included Medline, PubMed, Scopus, OVID, Springer Nature, and Cochrane CENTRAL. Outcomes assessed included stroke recurrence, hemorrhagic transformation, major bleeding, mortality, functional outcomes, and thromboembolic events. Data extraction and bias assessment were performed independently, and meta-analyses using random-effects models were conducted with RevMan 5.4, reporting relative risk (RR) and 95% confidence intervals.

Results:

Seventeen studies (13 quantitative; >32,000 participants) showed no significant difference in all-cause mortality or major extracranial bleeding between early and delayed OAC initiation. Sensitivity analyses indicated that early anticoagulation reduced ischemic events and intracranial hemorrhage without increasing major bleeding risk.

Conclusions:

Early OAC initiation after ischemic stroke in AF patients may lower ischemic and intracranial hemorrhage risks without increasing major bleeding. However, as most evidence is observational, high-quality randomized trials are needed to confirm these findings.

10.1212/WNL.0000000000213118
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