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Anticoagulants for acute ischaemic stroke.

Xia Wang1, Menglu Ouyang1, Jie Yang2

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Early anticoagulation for acute ischemic stroke does not improve patient outcomes or reduce mortality. While it lowers the risk of recurrent stroke and pulmonary embolism, it significantly increases bleeding complications, outweighing potential benefits.

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Area of Science:

  • Neurology
  • Cardiovascular Medicine
  • Pharmacology

Background:

  • Ischemic stroke, often caused by brain artery blood clots, is a leading global cause of death.
  • Early anticoagulation aims to prevent new clots without increasing bleeding risk, potentially improving patient outcomes.
  • This is an updated Cochrane Review, with previous versions published in 1995, 2004, 2008, and 2015.

Purpose of the Study:

  • To evaluate the effectiveness and safety of initiating anticoagulation within 14 days of acute ischemic stroke onset.
  • To determine if early anticoagulation reduces death or disability, recurrent strokes, or increases bleeding events.
  • To assess the impact on deep vein thrombosis and pulmonary embolism.

Main Methods:

  • Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing early anticoagulation with control.
  • Searched multiple databases including Cochrane Stroke Group Trials Register, CDSR, CENTRAL, MEDLINE, and Embase up to August 2021.
  • Included 28 RCTs with 24,025 participants; assessed risk of bias and certainty of evidence using RoB1 and GRADE.

Main Results:

  • Early anticoagulation did not reduce the odds of death or dependence (OR 0.98, high-certainty evidence).
  • A reduction in recurrent ischemic strokes (OR 0.75, moderate-certainty) was observed, but with increased symptomatic intracranial hemorrhage (OR 2.47, moderate-certainty).
  • Pulmonary embolism frequency decreased (OR 0.60, high-certainty), yet this was offset by increased extracranial hemorrhage (OR 2.99, moderate-certainty).

Conclusions:

  • Current data do not support the routine use of early anticoagulants for acute ischemic stroke.
  • While anticoagulants reduced recurrent strokes and embolisms, they increased bleeding risks, showing no net benefit.
  • Conclusions remain consistent with previous reviews, indicating no short- or long-term advantage from early anticoagulation.