Rivaroxaban Initiation Timing and Clinical Outcomes After Acute Ischemic Stroke in Patients with Non-Valvular Atrial Fibrillation: An IPTW-Based Cohort Study

BackgroundThe optimal timing of anticoagulation initiation after acute ischemic stroke (AIS) in patients with non-valvular atrial fibrillation (NVAF) remains uncertain. We evaluated the association between early versus delayed rivaroxaban initiation and clinical outcomes in this population.MethodsIn this retrospective, single-center cohort study, 401 hospitalized AIS patients with NVAF receiving rivaroxaban between January 2019 and June 2024 were classified into early (≤7 days) or delayed (>7 days) initiation groups. Primary outcomes were excellent [modified Rankin Scale (mRS) 0-1] and good (mRS 0-2) functional outcomes at 90 days and 12 months. Secondary outcomes included recurrent ischemic stroke, clinically relevant major bleeding, all-cause mortality, composite outcomes, and in-hospital length of stay (LOS). Inverse probability of treatment weighting (IPTW) was applied, followed by regression analyses. Sensitivity and subgroup analyses were performed.ResultsAfter IPTW adjustment, early rivaroxaban initiation was associated with a higher likelihood of achieving mRS 0-1 at 90 days (aOR 1.76, 95% CI 1.02-3.05) and 12 months (aOR 1.82, 95% CI 1.08-3.06), as well as a shorter LOS. No significant differences were observed for mRS 0-2 or other secondary outcomes. Sensitivity analyses yielded consistent results, and subgroup analyses suggested a trend toward greater benefit among patients with higher baseline stroke severity (NIHSS >7).ConclusionEarly rivaroxaban initiation after AIS in patients with NVAF was associated with improved excellent functional outcomes without an apparent increase in adverse events, supporting its potential feasibility in routine practice and warrant confirmation in larger prospective studies.