Objective To systematically evaluate the efficacy and safety of early initiation of oral anticoagulation in patients with acute ischemic stroke (IS) and non-valvular atrial fibrillation (NVAF).

Methods PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, and VIP databases were searched to collect clinical studies on early versus delayed oral anticoagulation for IS complicated by NVAF from inception to December 31, 2025. Two reviewers independently screened the literature, extracted data, and assessed the quality of included studies. Meta-analysis was performed using R software.

Results A total of 11 studies involving 9,293 patients (4,264 in the early anticoagulation group and 5,029 in the delayed anticoagulation group) were included. Meta-analysis showed that there were no statistically significant differences between the early and delayed anticoagulation groups in the risk of recurrent IS or transient ischemic attack [RR=0.86, 95%CI (0.68, 1.08)], composite outcome [RR=0.87, 95%CI (0.72, 1.05)], symptomatic intracranial hemorrhage [RR=0.97, 95%CI (0.54, 1.73)], major bleeding [RR=1.28, 95%CI (0.68, 2.42)], and all-cause mortality [RR=0.87, 95%CI (0.74, 1.03)]. Subgroup analysis showed that very early initiation (<3 days) was associated with an increased risk of major bleeding [RR=2.60, 95%CI (1.20, 5.63)]; however, this finding was based on only 3 small-sample studies.

Conclusion In patients with acute IS and NVAF, early initiation of oral anticoagulation showed a trend toward reducing the risk of recurrent IS or transient ischemic attack, though the difference was not statistically significant, and did not significantly increase the risks of symptomatic intracranial hemorrhage, all-cause mortality, and major bleeding. Future high-quality studies are needed to further refine the optimal timing and individualized dosing strategies for NOACs.

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