Optimal Timing of Anticoagulation Initiation in Stroke Patients With Atrial Fibrillation: A Systematic Review

This systematic review evaluates the optimal timing of anticoagulation in atrial fibrillation patients with acute ischemic stroke or transient ischemic attack. A comprehensive search across PubMed (94 records), Web of Science (121 records), Scopus (156 records), and the Cochrane Library (83 records) yielded 454 records. After screening 324 records and assessing 44 full texts, 13 studies were included: five randomized controlled trials and eight cohort studies, excluding those without comparisons of early versus delayed anticoagulation. The review analyzes studies comparing early and delayed initiation of oral anticoagulants (primarily direct oral anticoagulants (DOACs) and warfarin), focusing on outcomes such as recurrent ischemic stroke, symptomatic intracranial hemorrhage (sICH), and composite endpoints including recurrent stroke, sICH, systemic embolism, or mortality. Findings suggest that early anticoagulation, especially with DOACs, is safe and may reduce recurrent events without increasing the risk of sICH, particularly in cases with mild to moderate severity. However, varying definitions of timing, study designs, and limited data on severe strokes or in low-resource settings highlight research gaps. Future studies should investigate long-term outcomes and diverse populations to refine guidelines, particularly in resource-constrained environments.