This meta-analysis of randomized trials compared early versus late anticoagulation initiation after acute ischemic stroke in AF patients, providing the pooled evidence to guide the timing of DOAC start after cerebrovascular events.
The optimal timing for anticoagulation after acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) remains unclear. This meta-analysis compared the efficacy and safety of early versus late anticoagulation initiation.
A systematic search of PubMed, Embase, Cochrane CENTRAL, and ScienceDirect (up to June 2025) identified randomized controlled trials (RCT) comparing early and late anticoagulation in adults with AIS and AF. Outcomes included a composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or death, plus individual outcomes for mortality, recurrent stroke, hemorrhagic events, and functional independence. Data were pooled using random-effects models to calculate risk ratios (RR) with 95% confidence intervals (CI).
Four RCT (6722 patients) were included. The primary outcome occurred in 3.9% with early and 4.8% with late anticoagulation (RR 0.81; 95% CI 0.63-1.04; p = 0.10; I²=3.8%). Among patients receiving reperfusion therapy, rates were 3.2% vs. 3.9% (RR 0.83; 95% CI 0.53-1.28; p = 0.40). Mortality was 6.9% vs. 7.2% (RR 0.96; 95% CI 0.80-1.14; p = 0.61), ischemic stroke 2.3% vs. 2.9% (RR 0.77; 95% CI 0.53-1.13; p = 0.19), hemorrhagic events 0.8% vs. 1.3% (RR 0.68; 95% CI 0.41-1.13; p = 0.14), and functional independence (mRS 0-2) 66.3% vs. 65.4% (RR 1.01; 95% CI 0.95-1.07; p = 0.75).
Early anticoagulation after AIS in AF patients showed comparable efficacy and safety to delayed initiation, supporting its use in appropriately selected patients with predominantly mild-to-moderate ischemic stroke.
