Key result
Early OAC in moderate-severe stroke linked to ~352% higher odds of catastrophic outcomes vs late initiation.
Why the study?
The optimal timing for initiating oral anticoagulants after atrial fibrillation-related acute ischemic stroke remains controversial, especially regarding the risk-benefit threshold within 48 hours.
Does early oral anticoagulant initiation (≤48 hours) improve outcomes compared to late initiation (>48 hours) in patients with atrial fibrillation-related acute ischemic stroke?
Cohort (n=513)
Does early oral anticoagulant initiation (≤48 hours) improve outcomes compared to late initiation (>48 hours) in patients with atrial fibrillation-related acute ischemic stroke?
Ultra-early OAC initiation (≤48 hours) appears safe for mild AF-related ischemic stroke but significantly increases the risk of catastrophic outcomes in moderate-severe stroke, where a delay of 5-6 days is recommended.
Answers are grounded in this paper and cite their sources.
Cautions against early OAC after moderate-severe stroke; leaves open optimal timing pending confirmatory RCTs.
Background and aims The optimal timing for initiating oral anticoagulants (OAC) after atrial fibrillation(AF)-related acute ischemic stroke remains controversial, particularly regarding the risk-benefit threshold within the "ultra-early" window (<48 hours). This study aimed to delineate the relationship between OAC initiation timing and outcomes. Methods We conducted a retrospective cohort study of 513 patients with atrial fibrillation-related acute ischemic stroke. Patients were stratified by National Institutes of Health Stroke Scale (NIHSS) scores into mild (<8) and moderate-severe (≥8) groups. We compared favorable outcomes and catastrophic outcomes (recurrent stroke or mortality) within 90 days between early (≤48 hours) and late (>48 hours) OAC initiation. Restricted cubic spline (RCS) regression and multivariate logistic regression were employed. Results In mild stroke (n=249), early OAC initiation showed no significant difference in favorable outcomes or catastrophic outcomes compared to late initiation, with RCS identifying the lowest mortality risk at 7 hours. Conversely, in the moderate-severe group (n=264), early initiation was associated with significantly higher catastrophic outcomes (36.7% vs. 12.4%, P <0.001) and was independently associated with a 4.52-fold increased risk of catastrophic outcomes (aOR 4.52, 95% CI 1.35–15.17). RCS analysis indicated that mortality risk in moderate-severe patients stabilized between 5 and 6 days (119–139 hours). Conclusions The safety of ultra-early OAC initiation is severity-dependent. While immediate initiation appears safe for mild stroke, initiating within 48 hours for moderate-severe stroke significantly increases mortality risk. A delay of 5–6 days is recommended for patients with moderate-severe deficits to minimize catastrophic outcomes. Conflict of interest Po-Lin Chen:nothing to disclose; Chi-Sheng Wang: nothing to disclose; Ting-Ya Chang: nothing to disclose.
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Chen et al. (2026) conducted a cohort in Atrial fibrillation-related acute ischemic stroke (n=513). Early OAC initiation (≤48 hours) vs. Late OAC initiation (>48 hours) was evaluated on Catastrophic outcomes (recurrent stroke or mortality) within 90 days in moderate-severe stroke group (aOR 4.52, 95% CI 1.35–15.17, p=<0.001). Early OAC initiation (≤48 hours) in moderate-severe stroke significantly increased the risk of catastrophic outcomes compared to late initiation (36.7% vs 12.4%; aOR 4.52, 95% CI 1.35–15.17).
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