Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis-Reference-Cited by-同舟云学术

Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis

Published:2024-05-14 Issue: Volume: Page:
ISSN:2396-9873
Container-title:European Stroke Journal
language:en
Short-container-title:European Stroke Journal

Author:

Palaiodimou Lina¹^ORCID,Stefanou Maria-Ioanna¹,Katsanos Aristeidis H²^ORCID,De Marchis Gian Marco³⁴,Aguiar De Sousa Diana⁵^ORCID,Dawson Jesse⁶^ORCID,Katan Mira⁷⁸,Karapanayiotides Theodore⁹,Toutouzas Konstantinos¹⁰,Paciaroni Maurizio¹¹^ORCID,Seiffge David J¹²^ORCID,Tsivgoulis Georgios¹^ORCID

Affiliation:

1. Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

2. Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada

3. Department of Clinical Research, University of Basel, Basel, Switzerland

4. Department of Neurology and Stroke Center, Kantonsspital St. Gallen, Switzerland

5. Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal

6. Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

7. Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland

8. Department of Neurology, University Hospital and University of Basel, Basel, Switzerland

9. Second Department of Neurology, School of Medicine, Faculty of Health Sciences, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

10. First Department of Cardiology, National and Kapodistrian University of Athens, “Hippokration” Hospital, Athens, Greece

11. Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy

12. Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

Abstract

Introduction: There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. Methods: We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. Results: Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56–0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43–0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57–1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40–1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61–1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. Conclusions: Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.

Publisher

SAGE Publications

Link

https://journals.sagepub.com/doi/pdf/10.1177/23969873241251931

Reference36 articles.

1. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

2. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation

3. Early recurrent embolism associated with nonvalvular atrial fibrillation: a retrospective study.

4. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association

5. EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary†