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Resuming anticoagulation in patients with atrial fibrillation experiencing intracranial hemorrhage
Victor Chien-Chia Wu1,2, Yi-Chun Huang1, Shao-Wei Chen3
1Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.
Insights
Resuming oral anticoagulants (OACs) after intracranial hemorrhage (ICH) in atrial fibrillation (AF) patients significantly reduces mortality and stroke risk. This study found no increased risk of recurrent ICH when OACs were restarted.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Atrial fibrillation (AF) patients often receive oral anticoagulants (OACs) like warfarin for stroke prevention.
- Intracranial hemorrhage (ICH) in AF patients on OACs creates a treatment dilemma regarding anticoagulant continuation.
- Investigating the safety and efficacy of resuming OACs post-ICH is crucial for patient management.
Purpose of the Study:
- To determine if resuming OACs after ICH in AF patients is beneficial for preventing adverse outcomes.
- To compare the risks of mortality, ischemic stroke (IS), and systemic embolism (SE) between patients who resumed and discontinued OACs.
- To assess the rate of recurrent ICH in AF patients who resumed OACs post-ICH.
Main Methods:
- Retrospective analysis of electronic medical records of AF patients discharged with ICH (2001-2013).
- Patients were categorized into OAC resumption or discontinuation groups; propensity score matching was used for comparison.
- Primary outcomes included mortality/IS/SE, IS/SE, and recurrent ICH at 6 months and 1 year.
Main Results:
- Resuming OACs was associated with significantly lower rates of mortality/IS/SE and IS/SE at both 6 months and 1 year.
- Hazard ratios for mortality/IS/SE were 0.39 (6 months) and 0.56 (1 year) for OAC resumption.
- No significant difference in the rate of recurrent ICH was observed between the groups.
Conclusions:
- Resuming OAC therapy after ICH in AF patients is linked to reduced risks of mortality and thromboembolic events.
- The study suggests that the benefits of OAC resumption outweigh the risks concerning recurrent ICH.
- Clinical guidelines may need to consider OAC re-initiation in select AF patients post-ICH.
Abstract:
Globally, 32% to 70% patients with atrial fibrillation (AF) are prescribed oral anticoagulants (OACs) with warfarin for stroke prevention. However, patients with AF on OACs may experience intracranial hemorrhage (ICH), which presents a treatment dilemma. We therefore investigated whether resuming OACs in these patients is beneficial. Electronic medical records of patients with AF on OACs discharged with ICH between 2001 and 2013 were retrieved from the Taiwan National Health Insurance Research Database for analysis. We excluded patients who were <20 years old, who were not using OACs 6 months prior to ICH, or who had a CHA2DS2-VASc score of ≤1. We also excluded patients who died during admission for ICH, with follow-up for <6 weeks after discharge, or who started OAC >6 weeks after ICH diagnosis. The remaining patients were categorized into those who resumed OAC and those who discontinued OAC. Propensity score matching was performed between the 2 groups. Primary outcomes were mortality/ischemic stroke (IS)/systemic embolism (SE), IS/SE, and recurrent ICH at 6 months and 1 year. After the exclusion criteria were applied, 604 eligible patients (408 discontinued OAC and 196 resumed OAC within 6 weeks) were included in this study, and 186 patients in each group were 1:1 matched. Patients who resumed OAC had significantly lower mortality/IS/SE (hazard ratio [HR] = 0.39, 95% confidence interval [CI] = 0.20-0.76) and IS/SE (HR = 0.12, 95% CI = 0.03-0.53) at 6-month follow-up than patients who discontinued OAC. In addition, patients who resumed OAC had significantly lower mortality/IS/SE (HR = 0.56, 95% CI = 0.34-0.93) and IS/SE (HR = 0.26, 95% CI = 0.09-0.75) at 1-year follow-up. No difference in recurrent ICH was noted between the 2 groups. In conclusion, in patients with AF on OACs with ICH, resuming anticoagulant use was associated with significantly lower risks of composite outcomes of mortality/IS/SE and IS/SE than patients who discontinued OACs. No difference in recurrent ICH was observed between the 2 groups.
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