Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis

Lina Palaiodimou¹, Maria-Ioanna Stefanou¹, Aristeidis H Katsanos², Maurizio Paciaroni³, Simona Sacco⁴, Gian Marco De Marchis⁵, Ashkan Shoamanesh², Konark Malhotra⁶, Diana Aguiar de Sousa^{7

8}, Vaia Lambadiari⁹, Maria Kantzanou¹⁰, Sofia Vassilopoulou¹¹, Konstantinos Toutouzas¹², Dimitrios K Filippou^{13

14}, David J Seiffge^{5

15}, Georgios Tsivgoulis^{1

16}

Affiliations

¹ Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece.
² Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada.
³ Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, 06129 Perugia, Italy.
⁴ Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
⁵ Neurology and Stroke Center, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland.
⁶ Department of Neurology, Allegheny Health Network, Pittsburgh, PA 15212, USA.
⁷ Stroke Center, Lisbon Central University Hospital, 1649-024 Lisbon, Portugal.
⁸ Institute of Anatomy and CEEM, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal.
⁹ Second Department of Internal Medicine, Research Institute and Diabetes Center, "Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece.
¹⁰ Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹¹ First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece.
¹² First Department of Cardiology, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹³ Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹⁴ National Organization for Medicines (EOF), 15562 Athens, Greece.
¹⁵ Neurology and Stroke Center, Inselspital, University Hospital Bern, 3010 Bern, Switzerland.
¹⁶ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.

PMID: 36078915
PMCID: PMC9457225
DOI: 10.3390/jcm11174981

Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis

Lina Palaiodimou et al. J Clin Med. 2022.

. 2022 Aug 25;11(17):4981.

doi: 10.3390/jcm11174981.

Authors

Affiliations

¹ Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece.
² Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada.
³ Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, 06129 Perugia, Italy.
⁴ Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
⁵ Neurology and Stroke Center, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland.
⁶ Department of Neurology, Allegheny Health Network, Pittsburgh, PA 15212, USA.
⁷ Stroke Center, Lisbon Central University Hospital, 1649-024 Lisbon, Portugal.
⁸ Institute of Anatomy and CEEM, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal.
⁹ Second Department of Internal Medicine, Research Institute and Diabetes Center, "Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece.
¹⁰ Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹¹ First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece.
¹² First Department of Cardiology, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹³ Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
¹⁴ National Organization for Medicines (EOF), 15562 Athens, Greece.
¹⁵ Neurology and Stroke Center, Inselspital, University Hospital Bern, 3010 Bern, Switzerland.
¹⁶ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.

PMID: 36078915
PMCID: PMC9457225
DOI: 10.3390/jcm11174981

Abstract

Introduction: There is uncertainty regarding the optimal timing for initiation of oral anticoagulation in patients with acute ischemic stroke (AIS) due to atrial fibrillation (AF). Methods: We performed a systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) and prospective observational studies to assess the efficacy and safety of early anticoagulation in AF-related AIS (within 1 week versus 2 weeks). A second comparison was performed assessing the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin-K antagonists (VKAs) in the two early time windows. The outcomes of interest were IS recurrence, all-cause mortality, symptomatic intracerebral haemorrhage (sICH) and any ICH. Results: Eight eligible studies (6 observational, 2 RCTs) were identified, including 5616 patients with AF-related AIS who received early anticoagulation. Patients that received anticoagulants within the first week after index stroke had similar rate of recurrent IS, sICH and all-cause mortality compared to patients that received anticoagulation within two weeks (test for subgroup differences p = 0.1677; p = 0.8941; and p = 0.7786, respectively). When DOACs were compared to VKAs, there was a significant decline of IS recurrence in DOAC-treated patients compared to VKAs (RR: 0.65; 95%CI: 0.52-0.82), which was evident in both time windows of treatment initiation. DOACs were also associated with lower likelihood of sICH and all-cause mortality. Conclusions: Early initiation of anticoagulation within the first week may have a similar efficacy and safety profile compared to later anticoagulation (within two weeks), while DOACs seem more effective in terms of IS recurrence and survival compared to VKAs.

Keywords: anticoagulant; atrial fibrillation; direct oral anticoagulants; intracerebral haemorrhage; ischemic stroke; secondary prevention; vitamin-K antagonists.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

**Figure 1**
Forest plot presenting the pooled proportion of patients with recurrent IS following the initiation of oral anticoagulants, stratified by the timing of treatment initiation [10,11,18,19,20,21,23].

**Figure 2**
Forest plot presenting the risk ratio of recurrent IS among patients treated with DOACs versus VKAs, stratified by the timing of treatment initiation [10,11,23].

See this image and copyright information in PMC

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Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis

Affiliations

Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources