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Restarting Anticoagulation After Intracerebral Hemorrhage in Patients With Atrial Fibrillation | Journal Scan
Study Questions:
Is it safe to restart anticoagulation in patients with atrial fibrillation (AF) after an intracerebral hemorrhage (ICH)?
Methods:
The authors linked three Danish databases to capture patients with a diagnosis of AF and hospitalization for ICH between January 1997 and December 2013, as well as prescription of an antiplatelet agent or anticoagulant (vitamin K agonist or new oral anticoagulant) within 6 months prior to the ICH. Adverse events after the ICH, including stroke and systemic embolism, all-cause mortality, and recurrent ICH, were identified after a 6-week quarantine period after discharge from the index ICH. Patients were assumed to not be on any antithrombotic therapy after discharge from the index ICH and were assigned to either antiplatelet agent or anticoagulant groups, depending on which one was prescribed first. Patients were followed until an outcome event, death, emigration, or end of study. A Cox proportional hazard model was used to calculate event rates for patients on antithrombotic therapy compared with no-antithrombotic therapy. Analyses were adjusted for year of ICH, gender, time between anticoagulant prescription and ICH, CHA2DS2-VASc score, HAS-BLED score, and events during the quarantine period.
Results:
There were 1,752 patients included in the analysis. These were patients at high risk of embolism (mean CHA2DS2-VASc score, 3.9) and bleeding (mean HAS-BLED score, 3.2). At 1 year of follow-up, the rate of ischemic stroke, systemic embolism, or all-cause mortality (per 100 person-years) was 13.6 in the oral anticoagulant group compared with 25.7 in the antiplatelet group, and 27.3 in the no-antithrombotic group (anticoagulant compared with no antithrombotic, adjusted hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.39-0.78; anticoagulant compared with antiplatelet adjusted HR, 0.87; 95% CI, 0.67-1.14). At 1 year, in the anticoagulant group, the rate (per 100 person-years) of ischemic stroke and systemic embolism was 5.3 compared with 10.4 in the no-antithrombotic group (adjusted HR, 0.58; 95% CI, 0.33-1.03) and 10.3 in the antiplatelet group (adjusted HR, 0.98; 95% CI, 0.65-1.49). For all-cause mortality at 1 year, the rate (per 100 person-years) was 9.7 in the anticoagulant group compared with 19.1 in the no-antithrombotic group (adjusted HR, 0.55; 95% CI, 0.37-0.82) and 19.5 in the antiplatelet group (adjusted HR, 0.90; 95% CI, 0.67-1.21). The rate (per 100 person-years) of recurrent ICH in the anticoagulant group was 8.6 versus 8.0 in the no-antithrombotic group (adjusted HR, 0.91; 95% CI, 0.56-1.49) and 5.3 in the antiplatelet group (adjusted HR, 0.60; 95% CI, 0.37-1.03). At 5 years, patients treated with anticoagulation were more likely to be alive than those on antiplatelet therapy or no antithrombotic therapy.
Conclusions:
In patients with AF who have an ICH, anticoagulation after the ICH is associated with a reduction in ischemic stroke and all-cause mortality.
Perspective:
Patients with AF benefit from anticoagulation; however, anticoagulation increases the risk of ICH. After a patient with AF has an ICH, it is unclear if anticoagulation should be restarted because the risks of bleeding must be balanced against the benefits of reducing the risk of ischemic stroke. This study suggests that patients with AF benefit from anticoagulation after an ICH. Antiplatelet therapy is sometimes thought of as a lower risk alternative to anticoagulation, but these results suggest the lower bleeding risk in this approach is outweighed by an increase in ischemic stroke. Caution is warranted when interpreting these results, as the quality of anticoagulation control and imaging results were not available in this study. Additionally, the timing of when to restart anticoagulation after an ICH is unclear. While additional research in this area is needed, these data suggested that patients with AF and an anticoagulation associated ICH benefit from restarting anticoagulation.
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cerebral Hemorrhage, Cohort Studies, Embolism, Fibrinolytic Agents, Hospitalization, Intracranial Hemorrhages, Mortality, Platelet Aggregation Inhibitors, Proportional Hazards Models, Quarantine, Stroke, Vascular Diseases, Vitamin K
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