Early versus Later Anticoagulation in Post-Stroke patients with Atrial Fibrillation: A systematic review and Meta-analysis

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and significantly increases the risk of ischemic stroke, one of its most serious complications. The intricate relationship between AF and stroke necessitates careful consideration in the timing of anticoagulant therapy initiation to prevent stroke recurrence, hemorrhagic transformation, and other complications. Aim This study aims to evaluate the efficacy and safety of early versus late initiation of anticoagulant treatment in patients with AF after an ischemic stroke, addressing the critical gap in optimal timing to balance the risk of recurrent stroke against bleeding risks. Methods A systematic review and meta-analysis was conducted following the PRISMA-2020 guidelines, with searches performed across multiple databases including PubMed, Scopus, Web of Science, EMBASE, and Cochrane. Randomized controlled trials comparing early versus later initiation of anticoagulation in AF patients post-stroke were included. Data synthesis was performed using a random-effects model, considering recurrent ischemic stroke, symptomatic intracerebral hemorrhage, and mortality as primary outcomes. Results From 1444 identified records, three studies and 2989 patients were included, comprising a diverse population in terms of geography and demographics. Meta-analysis revealed that early anticoagulation initiation might be associated with a reduced risk of recurrent ischemic stroke (RR 0.72, 95% CI [0.51-1.00])(p=0.05), although statistical significance was borderline. No significant differences were found in symptomatic intracerebral hemorrhage or mortality rates between early and late initiation. Early intervention was, however, associated with a reduction in other adverse outcomes (RR 0.72, 95% CI [0.54-0.96])(p=0.03). Conclusions Early initiation of anticoagulation therapy in AF patients post-ischemic stroke may offer a protective effect against recurrent ischemic events with no significant increase in bleeding or mortality risks. This suggests that early anticoagulation can be safely considered, particularly in light of reducing other adverse outcomes.