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Analysis of Different NOACs for Intracerebral Hemorrhage
Study Questions:
What are the differences in clinical, imaging, and functional outcomes in patients who develop intracerebral hemorrhage (ICH) related to various non–vitamin K antagonist oral anticoagulants (NOACs)?
Methods:
The authors performed a multicenter observational cohort study of 1,328 patients with ICH related to NOAC or vitamin K antagonist (VKA) therapy between 2011 and 2015. Outcomes assessed included the imaging, clinical characteristics, and 3-month modified Rankin Scale. Propensity score matching was used to adjust for baseline differences.
Results:
Patients experiencing NOAC-related ICH (n = 190, mean 78.3 [standard deviation (SD) 7.8] years) were slightly older than those with VKA-related ICH (n = 1,054, mean 76.2 [SD 9.1] years) and had higher HAS-BLED scores (3 vs. 2, p = 0.049). However, these two groups had otherwise similar hematoma volume at baseline. The proportion of patients with hematoma expansion was similar, as was the proportion of patients with an unfavorable outcome at 3 months (modified Rankin Scale 4-6: 70.4% in NOAC group vs. 69.4% in VKA group, p = 0.79). In subgroup analysis, NOAC-treated patients with clinically-relevant anticoagulant activity at the time of ICH were more likely to have intraventricular hemorrhage (47.7% vs. 25.7%, p = 0.022) and hematoma expansion (38.9% vs. 16.7%, p = 0.040). There was no difference in imaging characteristics between different NOAC agents or dosing regimens.
Conclusions:
The authors concluded that there are no differences in hematoma characteristics and functional outcomes among patients with NOAC- vs. VKA-related ICH.
Perspective:
While it has been well established that patients treated with NOAC therapy (also known as direct oral anticoagulants [DOACs]) are significantly less likely to experience ICH as compared to patients treated with VKA, the outcomes associated with these serious events have been less robustly studied. This cohort study reports similar imaging characteristics (e.g., hematoma expansion) and clinical outcomes (modified Rankin Scale) among patients with ICH related to either VKAs or DOACs. However, there were worse outcomes among patients with meaningful anticoagulant levels of DOAC at the time of ICH as compared to those who had not been taking their NOAC recently. There was no difference in imaging or clinical outcomes seen between the different DOAC groups or doses. However, the relatively small sample size for this comparison means that the analysis was likely underpowered to detect differences.
Keywords: Anticoagulants, Cerebral Hemorrhage, Diagnostic Imaging, Hematoma, Outcome Assessment, Health Care, Secondary Prevention, Stroke, Vascular Diseases, Vitamin K
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