Early versus delayed direct oral anticoagulant initiation in nonvalvular atrial fibrillation–associated acute ischemic stroke: A systematic review and meta-analysis

IF 2 4区医学 Q3 NEUROSCIENCES

Journal of Stroke & Cerebrovascular Diseases Pub Date : 2025-06-05 DOI:10.1016/j.jstrokecerebrovasdis.2025.108371

Ekdanai Uawithya , Weerawat Saengphatrachai , Karan Srisurapanont , Kulsatree Praditukrit , Chitapa Kaveeta

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引用次数: 0

Abstract

Background

Early initiation of direct oral anticoagulants (DOACs) after acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) can prevent early recurrent AIS but may increase the risk of intracerebral hemorrhage (ICH). The appropriate DOAC initiation time remains uncertain. This systematic review and meta-analysis aimed to determine the optimal timing for DOAC initiation following NVAF-associated AIS.

Methods

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library from inception to March 2025. Eligible studies were randomized controlled trials and prospective cohort studies examining the effects of DOAC initiation timing in patients with NVAF-associated AIS. The primary outcome was the pooled risk ratio for a composite measure of ischemic and hemorrhagic events. Secondary outcomes were the pooled risk ratios for symptomatic ICH, recurrent AIS, major extracranial bleeding, and mortality. Subgroup analyses examined patients initiating DOACs within 3 days of stroke onset and compared outcomes based on baseline stroke severity (NIHSS < 5 vs ≥ 5).

Results

Eleven studies from ten cohorts (12,388 participants) met the inclusion criteria. No significant differences were found between early and delayed DOAC initiation for the composite outcomes or for any secondary endpoint. Subgroup analyses revealed a nonsignificant increase in ICH risk among patients with early treatment and higher stroke severity (NIHSS ≥ 5). No significant differences in early ischemic stroke rate were observed in both subgroups.

Conclusions

Early DOAC initiation appears to be safe following NVAF-associated AIS, including in patients with moderate stroke severity. However, the rate of early recurrent ischemic stroke remains comparable between early and delayed initiation groups.

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非瓣膜性房颤相关急性缺血性卒中早期与延迟直接口服抗凝剂：一项系统回顾和荟萃分析

背景：非瓣膜性心房颤动（NVAF）患者急性缺血性卒中（AIS）后早期开始直接口服抗凝剂（DOACs）可以预防早期AIS复发，但可能增加脑出血（ICH）的风险。适当的DOAC启动时间仍不确定。本系统综述和荟萃分析旨在确定nvaf相关AIS后DOAC启动的最佳时机。方法：系统检索PubMed、Embase、Scopus和Cochrane图书馆自成立至2025年3月的文献。符合条件的研究是随机对照试验和前瞻性队列研究，研究DOAC起始时间对非瓣瓣性房颤相关AIS患者的影响。主要结果是缺血性和出血性事件的综合风险比。次要结局是症状性脑出血、复发性AIS、主要颅外出血和死亡率的合并风险比。亚组分析检查了卒中发作3天内开始DOACs的患者，并基于基线卒中严重程度比较了结果（NIHSS ）结果：来自10个队列（12,388名参与者）的11项研究符合纳入标准。对于综合结果或任何次要终点，早期和延迟DOAC起始没有发现显著差异。亚组分析显示，早期治疗和卒中严重程度较高的患者脑出血风险无显著增加（NIHSS ≥ 5）。两个亚组的早期缺血性卒中发生率无显著差异。结论：在非瓣膜性房颤相关AIS患者中，包括中度卒中严重程度的患者，早期开始DOAC似乎是安全的。然而，早期缺血性卒中复发率在早期和延迟启动组之间仍然具有可比性。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of Stroke & Cerebrovascular Diseases Medicine-Surgery

CiteScore

5.00

自引率

4.00%

发文量

583

审稿时长

62 days

期刊介绍： The Journal of Stroke & Cerebrovascular Diseases publishes original papers on basic and clinical science related to the fields of stroke and cerebrovascular diseases. The Journal also features review articles, controversies, methods and technical notes, selected case reports and other original articles of special nature. Its editorial mission is to focus on prevention and repair of cerebrovascular disease. Clinical papers emphasize medical and surgical aspects of stroke, clinical trials and design, epidemiology, stroke care delivery systems and outcomes, imaging sciences and rehabilitation of stroke. The Journal will be of special interest to specialists involved in caring for patients with cerebrovascular disease, including neurologists, neurosurgeons and cardiologists.