Oral anticoagulation versus no anticoagulation for stroke prevention in patients with intracranial haemorrhage and atrial fibrillation: an updated meta-analysis of randomised controlled trials

Background Oral anticoagulation (OAC) effectively reduces stroke risk in patients with atrial fibrillation (AF), but its use after intracranial haemorrhage (ICH) remains controversial due to bleeding concerns. This study aimed to update the evidence on the efficacy and safety of OAC in patients with AF with a history of ICH. Methods A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched PubMed, Scopus and EMBASE for randomised controlled trials (RCTs) comparing OAC versus avoiding anticoagulation in patients with AF post-ICH. The primary outcomes were ischaemic stroke and recurrent ICH. Secondary outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), major haemorrhage and a composite endpoint of ‘net clinical benefit’ (first incident ischaemic stroke and first incident recurrent ICH). Pooled risk ratios (RRs) with 95% CIs were calculated using a random-effects model. Results Four RCTs with 653 participants were included. Anticoagulation was associated with a reduced risk of ischaemic stroke (RR 0.23, 95% CI 0.06 to 0.91) and increased risk of recurrent ICH (RR 3.60, 95% CI 1.40 to 9.30). No significant differences were observed in all-cause mortality (RR 0.93, 95% CI 0.59 to 1.46), cardiovascular death (RR 1.01, 95% CI 0.32 to 3.18) and for net clinical benefit (RR 0.72, 95% CI 0.42 to 1.24). Anticoagulation was associated with a significant increased risk of any major haemorrhage (RR 2.49, 95% CI 1.29 to 4.81) and reduced MACE (RR 0.64, 95% CI 0.44 to 0.94). Conclusions OAC in patients with AF and prior ICH was associated with a reduced risk of ischaemic stroke and an increased risk of recurrent ICH. PROSPERO registration number CRD42025637606.