Abstract 4338147: Early Versus Late Direct Oral Anticoagulant Initiation After Acute Ischemic Stroke With Atrial Fibrillation: A Bayesian Meta-Analysis of Randomized Controlled Trials

Introduction: The optimal timing to initiate direct oral anticoagulants (DOACs) after acute ischemic stroke in patients with atrial fibrillation (AF) remains uncertain. Objectives: To estimate the efficacy and safety of early versus late DOAC initiation in patients with AF after acute ischemic stroke using a Bayesian meta-analysis. Methods: We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs) evaluating this clinical question. Outcomes included ischemic events (recurrent ischemic stroke and systemic embolism) and hemorrhagic events (symptomatic intracranial hemorrhage and major extracranial bleeding). Odds ratios (ORs) with 95% credible intervals (CrIs) were calculated using a Bayesian random-effects model with non-informative priors. R software was used for statistical analyses. Results: We included 6749 patients from four RCTs, of whom 3324 (49.3%) received early treatment. Mean time to early DOAC initiation was 4 days post-stroke. Mean age was 76.8 years, and 3065 (45.4%) were female. All trials had a three-month follow-up. Among patients receiving early DOAC initiation, the median OR for ischemic events was 0.73 (95% CrI, 0.49-1.09; Figure 1A), with posterior probabilities of 95.3% for any benefit (OR < 1.0) and 68.4% for a meaningful benefit (OR < 0.8) (Figure 2A). For hemorrhagic events, the median OR was 0.81 (95% CrI, 0.40-1.68; Figure 1B), with posterior probabilities of 74.7% for any benefit and 50.6% for a meaningful benefit (Figure 2B). Conclusion: Early initiation of DOACs in patients with AF after acute ischemic stroke was associated with a probability of reduced ischemic events, without an apparent increase in hemorrhagic risk.