Timing of anticoagulation for patients with atrial fibrillation after acute ischemic stroke: Systematic review and meta-analysis

Patients with acute ischemic stroke (AIS) in the setting of atrial fibrillation (Afib) will need to start/resume anticoagulation (AC) as it is the mainstay for secondary stroke prevention. Several studies have compared the safety and outcomes of starting/resuming AC in early or late start windows (ESW or LSW) but there is no consensus in clinical practice on the optimal timing of anticoagulation. This meta-analysis aims to compare the safety and outcome measures after resuming AC in the ESW versus LSW in patients with Afib after AIS. Following the PRISMA guidelines, a comprehensive systematic review was conducted using PubMed, Embase, Web of Science, and Scopus. Studies meeting inclusion criteria underwent rigorous risk of bias assessment using the ROBINS-I tool. We compared the safety and outcome measures after resuming AC in the ESW versus LSW in patients with Afib after AIS. Using the R software version 4.3.1, meta-analyses were conducted employing random-effect models. This meta-analysis included data derived from 7 studies (2 randomized controlled trials and 5 prospective observational studies). Rates of recurrent ischemic stroke/transient ischemic attack (TIA) in patients who started AC in the ESW were comparable to those who started AC in the LSW (OR 0.72, 95 % CI 0.49–1.04; p = 0.083). Similarly, the rates of symptomatic intracranial hemorrhage (sICH) and mortality were comparable between the patients who started AC in the ESW versus LSW (OR 1.66, 95 % CI 0.43–6.47; p = 0.464) and (OR 0.88, 95 % CI 0.65–1.19; p = 0.402), respectively. Finally, using available data from 5 studies, rates of major bleeding were comparable as well between the patients who started AC in ESW versus LSW (OR 0.99, 95 % CI 0.50–1.96; p = 0.970). Among patients with Afib and AIS who are starting AC in the ESW versus LSW, there were no differences in the outcome measures, specifically stroke/TIA, sICH, mortality, or major bleeding.