Timing of Anticoagulation for Patients with Atrial Fibrillation After Acute Ischemic Stroke: Systematic Review and Meta-Analysis

Omar M Al-Janabi; Anas Odeh; Aryan Gajjar; Avi Misra; Yamama M Mahmood; Amira M Taha; Rishabh Gupta; Sherief Ghozy; Alejandro A Rabinstein; David F Kallmes

doi:10.1016/j.jstrokecerebrovasdis.2024.108159

Timing of Anticoagulation for Patients with Atrial Fibrillation After Acute Ischemic Stroke: Systematic Review and Meta-Analysis

J Stroke Cerebrovasc Dis. 2024 Nov 29:108159. doi: 10.1016/j.jstrokecerebrovasdis.2024.108159. Online ahead of print.

Authors

Affiliations

¹ Department of Neurology, Baptist Health Lexington, KY, USA. Electronic address: omar.aljanabi2020@gmail.com.
² Faculty of Medicine, An Najah National University, Nablus, Palestine.
³ University of California, Los Angeles, CA, USA.
⁴ Department of Neurology, Mayo Clinic, Rochester, MN, USA.
⁵ Pharmacy Service, University of Kentucky Healthcare, Lexington, KY, USA.
⁶ Faculty of Medicine, Fayoum University, Fayoum, Egypt.
⁷ Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
⁸ Department of Radiology, Mayo Clinic, Rochester, MN, USA.

PMID: 39617217
DOI: 10.1016/j.jstrokecerebrovasdis.2024.108159

Abstract

Background: 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.

Methods: 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.

Results: 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).

Conclusion: 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.

Keywords: Acute Ischemic Stroke; Anticoagulation; Atrial Fibrillation; Early Start Window; Late Start Window; Meta-analysis; Systematic Review.