Oral Anticoagulation Versus No Anticoagulation in Patients of Atrial Fibrillation With Prior History of Intracranial Hemorrhage: A Meta-Analysis

Atrial fibrillation is a major cause of ischemic stroke and systemic embolism. Oral anticoagulants (OACs) play a crucial role in preventing thromboembolic events in high-risk patients. However, evidence regarding initiation of OAC in patients with a prior intracranial hemorrhage (ICH) remains limited. We systematically searched PubMed, Scopus, and Cochrane Library for relevant articles published up to September 25, 2025, to evaluate the efficacy and safety of OACs in patients with atrial fibrillation and a history of ICH. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. A total of 9181 patients were included. OAC therapy significantly reduced ischemic stroke (RR: 0.38; 95% CI: 0.26–0.55; P < 0.00001) and ischemic stroke/systemic embolism (RR: 0.47; 95% CI: 0.36–0.61; P < 0.00001) when compared with no OAC therapy. OAC also reduced stroke-related mortality (RR: 0.55; 95% CI: 0.31–0.99; P = 0.04), all-cause mortality (RR: 0.68; 95% CI: 0.57–0.81; P < 0.0001), and major adverse cardiac events (RR: 0.69; 95% CI: 0.51–0.94; P = 0.02). However, its use was associated with a higher risk of major extracranial bleeding (RR: 1.70; 95% CI: 1.04–2.77; P = 0.03). There was no significant association between the use of OAC and recurrence of ICH (RR: 1.21; 95% CI: 0.69–2.13; P = 0.50). In conclusion, patients with previously documented ICH, OAC therapy substantially lowers the risk of ischemic stroke, systemic embolism, and major adverse cardiac events. There is no significant increase in intracranial bleeds with OAC. Prospective studies are needed to further refine the decision-making.