Early versus late oral anticoagulants after acute ischemic stroke in atrial fibrillation patients: a meta-analysis of randomized controlled trials

Background Atrial fibrillation (AF) occurs in about 20% of ischemic stroke cases. Although oral anticoagulants (OACs) reduce stroke risk in AF, the optimal timing for starting them after acute ischemic stroke remains uncertain, with varying recommendations across guidelines.Methods A systematic review and meta-analysis of randomized controlled trials was conducted using PubMed, Scopus, Web of Science, EMBASE, and Cochrane CENTRAL through October 2024. Studies included adults with AF and recent ischemic stroke, comparing early versus late OAC initiation. The primary outcome was recurrent ischemic stroke. Risk of bias was assessed using the Cochrane RoB2 tool.Results Three trials with 6522 patients were included. There were no significant differences between early and late OAC initiation in recurrent ischemic stroke (relative risk [RR] 0.82; 95% confidence interval [CI] 0.61–1.11; P = 0.19), major extracranial bleeding (RR 0.47; 95% CI 0.22–1.01; P = 0.05), intracranial hemorrhage (RR 0.93; 95% CI 0.44–1.96; P = 0.84), or mortality (RR 0.79; 95% CI 0.50–1.24; P = 0.30).Conclusion Early OAC initiation after ischemic stroke in AF appears as safe as later initiation, without higher bleeding or mortality risks. Given the elevated risk of early recurrence, prompt anticoagulation may be beneficial but requires further confirmation.