Resuming anticoagulants after anticoagulation-associated intracranial haemorrhage: systematic review and
Zien Zhou1,2, Jie Yu2,3, Cheryl Carcel2,4,5
1Department of Radiology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
Insights
Resuming anticoagulation after intracranial hemorrhage (ICH) in patients on anticoagulants is associated with fewer thromboembolic events and lower long-term mortality, particularly in those with atrial fibrillation. Further clinical trials are recommended.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Anticoagulation-associated intracranial hemorrhage (ICH) presents a complex clinical challenge regarding the resumption of anticoagulant therapy.
- Patients surviving acute ICH face risks of recurrent events, necessitating careful management decisions.
Purpose of the Study:
- To systematically review and meta-analyze adverse outcomes following the resumption of anticoagulation in patients who experienced anticoagulation-associated ICH.
- To evaluate the impact of resuming anticoagulant therapy on mortality, recurrent ICH, and thromboembolic events.
Main Methods:
- A systematic review and meta-analysis were conducted following PRISMA guidelines.
- Data were extracted from 12 cohort studies (3431 participants) identified through Medline, Embase, and Cochrane Central Register of Controlled Trials.
- Included studies focused on adults who received oral anticoagulants at the time of ICH and survived the acute phase.
Main Results:
- The pooled frequency of resuming anticoagulant therapy was 38%, higher in specific patient subgroups.
- Resuming anticoagulation was not associated with increased long-term mortality or ICH recurrence.
- Significantly fewer thromboembolic events were observed in patients who resumed anticoagulation (RR 0.31).
- In atrial fibrillation patients, resuming anticoagulation significantly reduced long-term mortality (RR 0.27).
Conclusions:
- Resuming anticoagulant therapy after anticoagulation-associated ICH appears to have beneficial effects on long-term complications, particularly reducing thromboembolic events.
- Observational data suggest a favorable risk-benefit profile for anticoagulation resumption in selected patients.
- Clinical trials are essential to confirm these findings from observational studies.
Objective:
To determine the adverse outcomes following resumption of anticoagulation in patients with anticoagulation-associated intracranial haemorrhage (ICH).
Design:
We performed a systematic review and meta-analysis in this clinical population. The Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement was followed, and two authors independently assessed eligibility of all retrieved studies and extracted data.
Data Sources:
Medline, Embase and the Cochrane Central Register of Controlled Trials, from inception to February 2017.
Eligibility Criteria And Outcomes:
Randomised controlled trials or cohort studies that recruited adults who received oral anticoagulants at the time of ICH occurrence and survived after the acute phase or hospitalisation were searched. Primary outcomes, including long-term mortality, recurrent ICH and thromboembolic events. Secondary outcomes were the frequency of resuming anticoagulant therapy and related factors.
Results:
We included 12 cohort studies (no clinical trials) involving 3431 ICH participants. The pooled frequency of resuming anticoagulant therapy was 38% (95% CI 32% to 44%), but this was higher in participants with prosthetic heart valves, subarachnoid haemorrhage or dyslipidaemia. There was no evidence that resuming anticoagulant therapy was associated with higher long-term mortality (pooled relative risk (RR) 0.60, 95% CI 0.30 to 1.19; p=0.14) or ICH recurrence (pooled RR 1.14, 95% CI 0.72 to 1.80; p=0.57). Resumption of anticoagulation was associated with significantly fewer thromboembolic events (pooled RR 0.31, 95% CI 0.23 to 0.42; p<0.001). In a subgroup of patients with atrial fibrillation, resuming anticoagulant therapy was associated with fewer long-term mortality (pooled RR 0.27, 95% CI 0.20 to 0.37, p<0.001).
Conclusions:
Based on these observational studies, resuming anticoagulant therapy after anticoagulation-associated ICH has beneficial effects on long-term complications. Clinical trials are needed to substantiate these findings.
Prospero Registration Number:
CRD42017063827.
Related Concept Videos
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:10Review and Preview
Percentiles are a type of fractile that partition data into...
01:13Review and Preview
01:20Random and Systematic Errors
01:09Directing Effect of Substituents: meta-Directing Groups