Key result
Early OAC initiation cuts post-stroke composite outcomes ~26% vs. late initiation in AF.
Why the study?
The optimal timing of initiating oral anticoagulants for non-valvular atrial fibrillation following acute ischemic stroke remains clinically uncertain, with current guidelines relying on expert opinion.
Does early initiation of oral anticoagulants reduce the composite of ischemic and hemorrhagic events and mortality compared to later initiation in patients with non-valvular atrial fibrillation following acute ischemic stroke?
Meta-Analysis (n=9,519)
Open-label
Yes
Does early initiation of oral anticoagulants reduce the composite of ischemic and hemorrhagic events and mortality compared to later initiation in patients with non-valvular atrial fibrillation following acute ischemic stroke?
Early initiation of oral anticoagulants after acute ischemic stroke in patients with non-valvular atrial fibrillation reduces the risk of recurrent ischemic stroke and composite adverse events without increasing intracranial hemorrhage or major bleeding compared to delayed initiation.
Answers are grounded in this paper and cite their sources.
Supports early oral anticoagulant initiation after atrial fibrillation stroke; extends two randomized trials with pooled observational data.
Introduction: There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. Methods: We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. Results: Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56–0.98; I 2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43–0.95; I 2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57–1.69; I 2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40–1.51; I 2 = 0%), and mortality (RR = 0.94; 95% CI:0.61–1.45; I 2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. Conclusions: Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.
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Palaiodimou et al. (2024) conducted a meta-analysis in Acute ischemic stroke and non-valvular atrial fibrillation (n=9,519). Early oral anticoagulant (OAC) initiation (≤2 to ≤7 days post-stroke) vs. Later oral anticoagulant (OAC) initiation (>2 to >7 days post-stroke) was evaluated on Composite of ischemic and hemorrhagic events and mortality at follow-up (RR 0.74, 95% CI 0.56–0.98, p=0.03). Early oral anticoagulant initiation after acute ischemic stroke in atrial fibrillation patients reduced the composite of ischemic, hemorrhagic, and mortality events compared to late initiation.
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