Abstract Number: Esoc2026a921 Navigating Anticoagulation Timing After Ischemic Stroke in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Abstract Background and aims The optimal timing for initiating oral anticoagulation (OACs) after acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) remains a major clinical issue. Clinicians must balance the prevention of early recurrent ischemic events against the potential risk of intracranial and systemic bleeding. The current study was conducted to evaluate the safety and efficacy of early versus delayed initiation of OACs after AIS in patients with AF. Methods We performed a comprehensive systematic review and meta-analysis of randomized controlled trials and observational studies comparing early versus delayed initiation of OACs following AIS in patients with AF. Pooled effect estimates were calculated using random-effects models. Outcomes of interest included recurrent ischemic stroke, intracranial hemorrhage, major bleeding, systemic embolism, and all-cause mortality. Heterogeneity was assessed using the I2 statistic, and subgroup analyses were conducted according to study design. Results Seventeen studies met inclusion criteria. Early initiation of OACs was associated with a significantly lower risk of recurrent ischemic stroke compared with delayed initiation (odds ratio OR 0.74, 95% confidence interval CI 0.58–0.95; p=0.02). Rates of intracranial hemorrhage did not differ significantly between groups, nor did rates of major bleeding, systemic embolism, or all-cause mortality. Subgroup analyses yielded consistent results, with low-to-moderate heterogeneity observed. Conclusions Early initiation of OACs after AIS in patients with AF is associated with a meaningful reduction in recurrent ischemic stroke without an apparent increase in bleeding complications or mortality. These findings support early anticoagulation strategies in appropriately selected patients and provide reassurance regarding their overall safety profile. Conflict of interest "Mohamed Shehata: nothing to disclose, Ahmed Elbassiouny: nothing to disclose"