Resuming Warfarin Treatment After Hemorrhagic Stroke or ICH

Study Questions:

What is the prognosis associated with resuming warfarin treatment stratified by the type of intracranial hemorrhage (ICH)?


The authors established a nationwide observational cohort study of patients with atrial fibrillation (AF) who sustained an incident ICH event during warfarin treatment between 1998 and 2016. Resumption of warfarin treatment was evaluated after hospital discharge. Outcomes assessed included subsequent ischemic stroke or systemic embolism risk, recurrent ICH risk, and all-cause mortality. The risk of these outcomes was adjusted for age, sex, length of hospital stay, comorbidities, and concomitant medication use.


Among 2,415 surviving patients with AF (61% men, mean age 77.1 years) who sustained an ICH, 1,325 (55%) were hemorrhagic stroke and 1,090 (45%) were secondary to trauma. During the first year, 305 patients with hemorrhagic stroke (23.0%) died, while 210 of the traumatic ICH patients (19.3%) died. Among patients with hemorrhagic stroke, resumption of warfarin therapy was associated with a nonsignificantly lower rate of subsequent ischemic stroke or systemic embolism (adjusted hazard ratio [aHR], 0.49; 95% confidence interval [CI], 0.24-1.02) and a nonsignificantly increased rate of recurrent ICH (aHF, 1.31; 95% CI, 0.68-2.50) as compared to not resuming warfarin. For patients with traumatic ICH, resuming warfarin was associated with a nonsignificantly lower rate of ischemic stroke or systemic embolism (aHF, 0.40; 95% CI, 0.15-1.11) and a statistically significantly lower rate of recurrent ICH (aHR, 0.45; 95% CI, 0.26-0.76). Mortality risk was lower among patients who resumed warfarin therapy in the hemorrhagic stroke cohort (aHR, 0.51; 95% CI, 0.37-0.71) and the traumatic ICH cohort (aHR, 0.35; 95% CI, 0.23-0.52).


The authors concluded that resumption of warfarin after a spontaneous hemorrhagic stroke in AF patients was associated with a lower rate of subsequent ischemic events and a higher rate of recurrent ICH. They also concluded that among patients with a traumatic ICH, resumption of warfarin was associated with a lower rate of ischemic events and a lower relative risk for recurrent ICH.


This nationwide cohort study explored the effects of resuming warfarin in AF patients who suffer a hemorrhagic stroke or traumatic ICH. Similar to prior studies, the overall effect was either not statistically significant or in favor of resuming warfarin. Most importantly, all-cause mortality risk was reduced by 50-65% among patients who restarted warfarin therapy. It is important to note that this analysis only applies to patients who survive the initial ICH event beyond 14 days post-hospital discharge. A minority of patients resumed warfarin therapy, suggesting that further work is needed to convince patients and clinicians of the benefits of resumed warfarin therapy even after an ICH event.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Comorbidity, Embolism, Intracranial Hemorrhages, Intracranial Hemorrhage, Traumatic, Secondary Prevention, Risk, Stroke, Vascular Diseases, Warfarin

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