Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada.
Eur Stroke J. 2024 Dec;9(4):885-895. doi: 10.1177/23969873241251931. Epub 2024 May 14.
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.
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.
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; = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated.
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.
在急性缺血性卒中后，非瓣膜性心房颤动患者开始口服抗凝剂（OAC）的最佳时机存在长期的临床不确定性。目前的国际建议是基于专家意见，而在日常实践中，临床医生之间存在显著的差异。
我们进行了一项更新的系统评价和荟萃分析，包括所有已发表的随机对照临床试验（RCT）和观察性队列研究，这些研究调查了急性缺血性卒中后非瓣膜性心房颤动患者早期与晚期 OAC 起始治疗的效果。主要结局定义为随访时的缺血性和出血性事件及死亡率的复合结局。次要结局包括复合结局的组成部分（缺血性卒中复发、颅内出血、大出血和全因死亡率）。使用随机效应模型计算汇总估计值。
纳入了 9 项研究（2 项 RCT 和 7 项观察性研究），共纳入 4946 例早期 OAC 起始治疗的患者和 4573 例晚期 OAC 起始治疗的患者。与晚期 OAC 起始治疗相比，早期 OAC 起始治疗与复合结局风险降低相关（RR=0.74；95%CI：0.56-0.98； = 46%）和缺血性卒中复发（RR=0.64；95%CI：0.43-0.95； = 60%）。关于安全性结局，颅内出血（RR=0.98；95%CI：0.57-1.69； = 21%）、大出血（RR=0.78；95%CI：0.40-1.51； = 0%）和死亡率（RR=0.94；95%CI：0.61-1.45； = 0%）的发生率相似。当分别评估 RCT 和观察性研究时，没有发现亚组差异。
与晚期 OAC 起始治疗相比，急性缺血性卒中合并非瓣膜性心房颤动患者早期 OAC 起始治疗似乎具有更好的疗效和相似的安全性。
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