{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T15:27:04Z","timestamp":1781191624341,"version":"3.54.1"},"reference-count":28,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T00:00:00Z","timestamp":1765152000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"KAU Endowment (WAQF) at king Abdulaziz University, Jeddah, Saudi Arabia"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Neurology International"],"abstract":"<jats:p>Background\/Objectives: The optimal timing for initiating oral anticoagulants (OACs) after acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) remains uncertain due to potential risks of recurrent stroke and bleeding. This meta-analysis compares early versus late OAC initiation for recurrent ischemic stroke, major bleeding, intracranial hemorrhage (ICH), systemic embolism, and all-cause mortality. Methods: We conducted a meta-analysis of randomized controlled trials (RCTs), prospective, and retrospective observational studies. Data were pooled using random-effects models, and subgroup analyses were performed to assess outcomes by study design. Heterogeneity was quantified using I2 statistics. Results: A total of 17 studies were included. Early OAC initiation was associated with a significantly lower risk of recurrent ischemic stroke compared to late initiation (OR = 0.74, 95% CI [0.58, 0.95], p = 0.02), with moderate heterogeneity (I2 = 36%, p = 0.08). No significant difference was observed in ICH rates (OR = 0.74, 95% CI [0.41, 1.33], p = 0.32), major bleeding (OR = 1.48, 95% CI [0.51, 4.30], p = 0.47), or systemic embolism (OR = 0.65, 95% CI [0.33, 1.25], p = 0.20). All-cause mortality showed no difference between early and late initiation (OR = 1.00, 95% CI [0.72, 1.39], p = 0.99). Subgroup analyses were consistent with overall findings, and heterogeneity ranged from low to moderate across outcomes. Conclusions: Early initiation of OACs post-AIS in AF patients significantly reduces ischemic stroke recurrence without increasing risks of ICH, major bleeding, systemic embolism, or mortality. These findings support early anticoagulation strategies for selected patients.<\/jats:p>","DOI":"10.3390\/neurolint17120198","type":"journal-article","created":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T14:52:24Z","timestamp":1765205544000},"page":"198","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Early Versus Late Anticoagulation for Acute Ischemic Stroke in Atrial Fibrillation: A Systematic Review and Meta-Analysis of 17,380 Patients"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4301-0041","authenticated-orcid":false,"given":"Duaa Abdullah","family":"Bafail","sequence":"first","affiliation":[{"name":"Department of Clinical Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abrar Abdullah","family":"Bafail","sequence":"additional","affiliation":[{"name":"Nuclear Medicine Department, Le Centre Hospitalier R\u00e9gional Universitaire, 37000 De Tours, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"917","DOI":"10.1002\/clc.23647","article-title":"Non-vitamin K antagonist oral anticoagulants versus vitamin K antagonists in atrial fibrillation patients with previous stroke or intracranial hemorrhage: A systematic review and meta-analysis of observational studies","volume":"44","author":"Guo","year":"2021","journal-title":"Clin. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1002\/phar.2345","article-title":"Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation","volume":"40","author":"Smythe","year":"2020","journal-title":"Pharmacotherapy"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1075","DOI":"10.1161\/CIRCRESAHA.121.319947","article-title":"Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies","volume":"130","author":"Yaghi","year":"2022","journal-title":"Circ. Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1161\/CIR.0000000000001193","article-title":"2023 ACC\/AHA\/ACCP\/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Joglar","year":"2024","journal-title":"Circulation"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Palaiodimou, L., Stefanou, M.I., Katsanos, A.H., Paciaroni, M., Sacco, S., De Marchis, G.M., Shoamanesh, A., Malhotra, K., de Sousa, D.A., and Lambadiari, V. (2022). Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis. J. Clin. Med., 11.","DOI":"10.3390\/jcm11174981"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2411","DOI":"10.1056\/NEJMoa2303048","article-title":"Early versus Later Anticoagulation for Stroke with Atrial Fibrillation","volume":"388","author":"Fischer","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1056","DOI":"10.1161\/CIRCULATIONAHA.122.060666","article-title":"Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study","volume":"146","author":"Oldgren","year":"2022","journal-title":"Circulation"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1161\/STROKEAHA.120.030042","article-title":"Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial","volume":"52","author":"Labovitz","year":"2021","journal-title":"Stroke"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1016\/j.ijsu.2010.02.007","article-title":"Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement","volume":"8","author":"Moher","year":"2010","journal-title":"Int. J. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.jclinepi.2020.06.015","article-title":"The revised Cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application","volume":"126","author":"Minozzi","year":"2020","journal-title":"J. Clin. Epidemiol."},{"key":"ref_11","unstructured":"Wells, G.A., Shea, B., O\u2019Connell, D., Peterson, J., Welch, V., Losos, M., and Tugwell, P. (2025, May 01). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Available online: https:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp."},{"key":"ref_12","unstructured":"Sch\u00fcnemann, H., Bro\u017cek, J., Guyatt, G., and Oxman, A. (2013). Handbook for Grading the Quality of Evidence and the Strength of Recommendations Using the GRADE Approach, GRADEpro. Update October 2013."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1136\/jnnp-2018-318890","article-title":"Early versus late anticoagulation for ischaemic stroke associated with atrial fibrillation: Multicentre cohort study","volume":"90","author":"Wilson","year":"2019","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Yasaka, M., Minematsu, K., Toyoda, K., Mori, E., Hirano, T., Hamasaki, T., Yamagami, H., Nagao, T., Yoshimura, S., and Uchiyama, S. (2019). Rivaroxaban administration after acute ischemic stroke: The RELAXED study. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0212354"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Al Bakr, A.I., AlOmar, R.S., Nada, M.A., Ishaque, N., Aljaafari, D., Hadhiah, K., Al Khmais, F.A., Zafar, A., Shahid, R., and Shariff, E.M. (2020). Timing to start anticoagulants after acute ischemic stroke with non-valvular atrial fibrillation. J. Neurol. Sci., 409.","DOI":"10.1016\/j.jns.2019.116582"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1161\/STROKEAHA.119.028118","article-title":"Early Initiation of Direct Oral Anticoagulants After Onset of Stroke and Short- and Long-Term Outcomes of Patients With Nonvalvular Atrial Fibrillation","volume":"51","author":"Mizoguchi","year":"2020","journal-title":"Stroke"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1177\/2396987320937116","article-title":"Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes","volume":"5","author":"Paciaroni","year":"2020","journal-title":"Eur. Stroke J."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Kimura, T., Tucker, A., Nakagaki, A., Sugimura, T., Fukuda, S., Katsuno, M., Fujita, T., Izumi, N., Suzuki, N., and Sako, K. (2021). Anticoagulation Protocol for Secondary Prevention of Acute Ischemic Stroke Associated with Nonvalvular Atrial Fibrillation. J. Stroke Cerebrovasc. Dis., 30.","DOI":"10.1016\/j.jstrokecerebrovasdis.2021.105893"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1136\/jnnp-2021-327236","article-title":"Early versus late start of direct oral anticoagulants after acute ischaemic stroke linked to atrial fibrillation: An observational study and individual patient data pooled analysis","volume":"93","author":"Seiffge","year":"2022","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1161\/STROKEAHA.121.036695","article-title":"Practical \u201c1-2-3-4-Day\u201d Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study","volume":"53","author":"Kimura","year":"2022","journal-title":"Stroke"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1169","DOI":"10.1177\/17474930231184366","article-title":"Early or late initiation of dabigatran versus vitamin-K-antagonists in acute ischemic stroke or TIA: The PRODAST study","volume":"18","author":"Grosse","year":"2023","journal-title":"Int. J. Stroke"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2084","DOI":"10.1007\/s00415-022-11515-y","article-title":"The optimum anticoagulation time after endovascular thrombectomy for atrial fibrillation-related large vessel occlusion stroke: A real-world study","volume":"270","author":"Ma","year":"2023","journal-title":"J. Neurol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1136\/svn-2023-002357","article-title":"Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: The ATTUNE study","volume":"9","author":"Sharobeam","year":"2024","journal-title":"Stroke Vasc. Neurol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2317","DOI":"10.1016\/j.jstrokecerebrovasdis.2016.06.031","article-title":"Early Initiation of Anticoagulation with Direct Oral Anticoagulants in Patients after Transient Ischemic Attack or Ischemic Stroke","volume":"25","author":"Macha","year":"2016","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1002\/ana.25844","article-title":"Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk","volume":"88","author":"Yaghi","year":"2020","journal-title":"Ann. Neurol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2099","DOI":"10.1007\/s00415-021-10788-z","article-title":"Early anticoagulation in atrial fibrillation-related acute ischaemic stroke: Efficacy and safety profile","volume":"269","author":"Fonseca","year":"2022","journal-title":"J. Neurol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"885","DOI":"10.1177\/23969873241251931","article-title":"Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis","volume":"9","author":"Palaiodimou","year":"2024","journal-title":"Eur. Stroke J."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., Shamseer, L., Tetzlaff, J.M., Akl, E.A., and Brennan, S.E. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. 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