Introduction: Fibrinogen-to-albumin ratio (FAR) is implicated in prothrombotic states and is associated with an increased risk of acute ischemic stroke (AIS). However, studies investigating whether the prothrombotic effect of FAR is associated with long-term adverse outcomes in patients with AIS are lacking. Therefore, we aimed to investigate the association based on the Third China National Stroke Registry (CNSR-III). Methods: Patients with AIS with complete laboratory data for fibrinogen and albumin in the CNSR-III were included in this study. The primary outcomes were poor functional outcomes (modified Rankin scale score 3–6) at 12 months, including disability (modified Rankin scale score 3–5), all-cause death, recurrent stroke, and combined vascular events within 1 year. Univariate and multivariate logistic or Cox regression analyses were used to investigate the association between FAR quartiles and adverse outcomes. Results: A total of 8,984 patients with AIS were enrolled in this study. After 1-year follow-up, 238 patients were lost to follow-up. A total of 1,230 (14.06%) patients had poor functional outcomes; 932 (10.37%) and 981 (10.92%) experienced stroke recurrence and combined vascular events, respectively. The adjusted odds ratios/hazard ratios and 95% confidence intervals of the highest quartile of the FAR (>11.44) were 1.64 (1.35–2.00) for poor functional outcomes, 1.68 (1.34–2.10) for disability, 1.40 (1.02–1.94) for all-cause death, 1.11 (0.92–1.34) for stroke recurrence, and 1.11 (0.92–1.33) for combined vascular event, respectively. Conclusion: High FAR (>11.44) increased the risk of short- and long-term poor functional outcomes, including disability and all-cause death among patients with AIS. The FAR may play an important role in the early stratification of patients with AIS.

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