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Published on: February 28, 2012
Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial
Elena Ivany1,2, Leona A Ritchie1,2, Gregory Y H Lip1,2,3,4
1Liverpool Centre for Cardiovascular Science (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.).
Insights
Oral anticoagulation (OAC) therapy in atrial fibrillation patients surviving intracranial hemorrhage (ICrH) reduces thromboembolic events and mortality without significantly increasing recurrent ICrH risk. Further trials are needed.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Atrial fibrillation patients surviving intracranial hemorrhage (ICrH) face a complex treatment decision.
- Balancing the risk of thromboembolic events against recurrent ICrH is critical.
Purpose of the Study:
- To systematically review the effectiveness and safety of oral anticoagulation (OAC) and/or antiplatelets.
- To assess OAC and antiplatelets in atrial fibrillation patients with nontraumatic ICrH.
Main Methods:
- Systematic review of CENTRAL, MEDLINE, EMBASE, and CINAHL databases.
- Inclusion of adult patients with atrial fibrillation and spontaneous ICrH receiving antithrombotic therapy.
- Analysis of 20 articles including RCTs, observational studies, and meta-analyses.
Main Results:
- OAC therapy significantly reduced thromboembolic events (sRR, 0.51) and all-cause mortality (sRR, 0.52).
- OAC therapy was not associated with a significantly increased risk of recurrent ICrH (sRR, 1.44).
- Non-vitamin K antagonist OACs showed greater efficacy in reducing thromboembolic events and a lower risk of recurrent ICrH compared to warfarin.
Conclusions:
- OAC therapy in ICrH survivors with atrial fibrillation reduces thromboembolic events and mortality.
- The risk of recurrent ICrH is not significantly increased with OAC therapy.
- Larger randomized controlled trials are necessary to confirm these findings, which are primarily based on observational data.
Background:
For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.
Methods:
This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.
Results:
Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)' 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30-0.86], heterogeneity I2=2%; P=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38-0.71], heterogeneity I2=0; P=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38-5.46], heterogeneity I2=70%, P=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44-0.97], heterogeneity I2=72%, P=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40-0.67], heterogeneity I2=0%, P=0.43, n=3 studies) than warfarin.
Conclusions:
In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.
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