Log in to MyACC
Cardioembolic Stroke Risk and Recovery After Anticoagulation-Related ICH
Study Questions:
What is the association between CHA2DS2-VASc score, oral anticoagulation therapy (OAT) resumption, and functional recovery among anticoagulation-related intracerebral hemorrhage (ICH) survivors who do not go on to have ischemic stroke or recurrent ICH?
Methods:
This prospective, observational study is an analysis of patient-level data from three observational studies enrolling 941 relevant ICH survivors. Included patients had primary ICH confirmed on computed tomography scan, were on OAT at the time of their ICH because of previously diagnosed atrial fibrillation, and had no functional impairment or dependence before the ICH. Patients were excluded if they were deceased or on comfort measures at the time of hospital discharge and if they had been diagnosed with recurrent ICH or ischemic stroke by 1-year follow-up. A CHA2DS2-VASc score was calculated for each included patient. Follow-up information collected at 3, 6, and 12 months included resumption of OAT yes/no, mortality yes/no, and modified Rankin scale score (mRS; a 7-point scale of post-stroke disability ranging from 0 [no symptoms] to 6 [dead]). Functional recovery was defined as achieving a mRS ≤3 at 1 year after ICH if mRS was >3 at discharge.
Results:
Of 941 patients, 262 patients (28%) resumed OAT. Increasing CHA2DS2-VASc score was inversely associated with functional recovery at 1 year (adjusted odds ratio, 0.83 per 1-point increase in CHA2DS2-VASc score; 95% confidence interval, 0.79–0.86) after adjustment for discharge mRS, ICH location (lobar vs. nonlobar), and exposure to antiplatelets. OAT resumption was associated with functional recovery in patients with higher CHA2DS2-VASc scores of 5-9, but not lower CHA2DS2-VASc scores of 0-4 (p for interaction = 0.01).
Conclusions:
Increasing CHA2DS2-VASc score is associated with less frequent functional recovery at 1 year after anticoagulation-related ICH, and this relationship appears independent of incident ischemic stroke (the first “s” in CHA2DS2-VASc). OAT resumption is associated with functional recovery in patients with higher CHA2DS2-VASc scores, but not lower CHA2DS2-VASc scores. The authors hypothesize that increasing CHA2DS2-VASc score is associated with silent cardioembolic infarcts that cause or worsen disability. The authors further hypothesize that resumption of OAT reduces the risk of these silent infarcts, thereby promoting functional recovery.
Perspective:
It is not surprising that higher CHA2DS2-VASc scores were associated with lower likelihood of functional recovery at 1 year after ICH given that a higher CHA2DS2-VASc score is associated with higher age and/or medical comorbidities such as diabetes, hypertension, chronic heart failure, and vascular disease. However, OAT resumption weakened this association at higher CHA2DS2-VASc scores, suggesting that resumption of OAT can reduce disability independent from its reduction in ischemic stroke risk. A prospective randomized trial with magnetic resonance imaging could lend support to the authors’ hypothesis that the benefit of OAT resumption is mediated by a reduction in silent ischemic cerebral injury.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Computed Tomography, Nuclear Imaging
Keywords: Anticoagulants, Atrial Fibrillation, Brain Ischemia, Cerebral Hemorrhage, Risk, Secondary Prevention, Stroke, Thrombolytic Therapy, Tomography, X-Ray Computed, Vascular Diseases
< Back to Listings
