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Published on: February 28, 2012
Anticoagulation therapy in atrial fibrillation after intracranial hemorrhage
Young-Ah Park1, Jae-Sun Uhm1, Hui-Nam Pak1
1Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
Insights
Oral anticoagulation therapy (OAT) in atrial fibrillation (AF) patients with a history of intracranial hemorrhage (ICH) is complex. Optimal OAT, initiated >2 weeks post-ICH with good therapeutic range, improves outcomes and reduces thromboembolic events.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- The use of oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) and a history of intracranial hemorrhage (ICH) is not well-established.
- Balancing the risk of thromboembolic events against the risk of bleeding is crucial in this patient population.
Purpose of the Study:
- To evaluate the efficacy and safety of OAT in patients diagnosed with AF and a prior history of ICH.
- To compare composite endpoints, including thromboembolic and major bleeding events, between patients on OAT and those not on OAT.
Main Methods:
- Retrospective comparison of patients with AF and ICH history, divided into OAT and no-OAT groups.
- Analysis of composite endpoints, major bleeding events, and thromboembolic events over a mean follow-up of 39.5 months.
- Assessment of the impact of time-in-therapeutic range (TTR) and timing of OAT initiation post-ICH.
Main Results:
- Major bleeding events occurred more frequently in the OAT group (5.5/100 patient-years) compared to the no-OAT group (3.1/100 patient-years).
- Recurrent ICH was exclusively observed in patients receiving OAT.
- Thromboembolic events were significantly lower in the OAT group (2.4/100 patient-years) versus the no-OAT group (8.3/100 patient-years).
- No significant difference in composite endpoints was found between the OAT and no-OAT groups.
- Patients achieving a TTR ≥60% demonstrated improved survival free of composite endpoints.
- Early OAT (<2 weeks post-ICH) did not improve composite endpoints due to increased bleeding; however, OAT initiated ≥2 weeks post-ICH was associated with decreased clinical events.
Conclusions:
- For AF patients with a history of ICH requiring anticoagulation, maintaining optimal OAT is associated with improved clinical outcomes.
- Achieving a time-in-therapeutic range (TTR) of ≥60% is linked to better cumulative survival.
- Initiating OAT at least 2 weeks after an index ICH event is recommended to reduce clinical events, including thromboembolic events.
Background:
The effect of oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) with a history of intracranial hemorrhage (ICH) is poorly defined.
Objective:
The purpose of this study was to evaluate the efficacy and safety of OAT in patients with AF with an ICH history.
Methods:
We retrospectively compared the composite end point, including thromboembolic and major bleeding events, between patients with AF with a history of ICH who were (OAT group, n = 254) and those who were not (no-OAT group, n = 174) taking OAT.
Results:
During a mean follow-up of 39.5 ± 31.9 months, 5.5 and 3.1 major bleeding events/100 patient-years were observed in the OAT and no-OAT groups, respectively (P = .024). Recurrent ICH was observed only in patient with OAT. Thromboembolic events occurred in 2.4 and 8.3 events/100 patient-years in OAT and no-OAT groups, respectively (P < .001). There was no significant differences in composite end points between OAT and no-OAT groups (11.5 events/100 patient-years vs 7.9 events/100 patient-years; P = .154). Patients with OAT who achieved a time-in-therapeutic range of ≥60% of the international normalized ratio of 2.0-3.0 demonstrated a better cumulative survival free of the composite end point (P < .001) than did patients without OAT. Early (<2 weeks) OAT after an index ICH did not improve composite end points because of the increased incidence of major bleeding events. However, OAT at 2 weeks after an index ICH was associated with decreased clinical events including thromboembolic events and composite end point.
Conclusion:
In patients with AF who require anticoagulation and have a history of ICH, maintaining optimal OAT with time-in-therapeutic range ≥ 60% and the initiation of OAT at least 2 weeks after an index ICH were associated with improved clinical outcomes.
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