Contemporary US Practice Patterns Regarding Anticoagulation and LAA Closure in ICH Survivors With Atrial Fibrillation

Optimal secondary stroke prevention remains uncertain for patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Anticoagulation reduces ischemic stroke in AF but increases hemorrhage. Left atrial appendage (LAA) occlusion is emerging as an alternative to anticoagulation, but few data exist on its safety in patients with ICH. Amid this uncertainty, little is known about US practice patterns in this scenario.

We performed a study using linked electronic health record, pharmacy, and insurance claims data on >11 million patients at 29 US healthcare organizations, each with multiple hospital sites, in the TriNetX Linked platform. Validated International Classification of Diseases, Tenth Revision codes were used to identify adults with AF hospitalized for ICH during 2016 to 2024. To identify antiplatelet and anticoagulant prescriptions, we used RxNorm codes, a standardized drug naming system from the National Library of Medicine. LAA occlusion was defined using validated Current Procedural Terminology codes. Kaplan-Meier statistics were used to calculate cumulative rates of therapy utilization from discharge through 5 years. We created 3 mutually exclusive treatment groups with censoring at LAA occlusion for analyses of antiplatelet and anticoagulant therapy and at anticoagulation for analyses of antiplatelet therapy.

We identified 2276 patients with AF hospitalized with ICH. Their mean age was 65.4 (±12.8) years, 40.6% were female, median CHA₂DS₂-VASc score was 5 (interquartile range, 5-6), 19.6% had Medicare, 26.9% received an anticoagulant prescription within 90 days before ICH, and half were discharged home or to an acute rehabilitation facility. Cumulative 5-year rates were 59.8% (95% CI, 55.5%-64.2%) for anticoagulation, 39.9% (95% CI, 34.1%-46.3%) for antiplatelet therapy, and 4.5% (95% CI, 2.6%-7.6%) for LAA occlusion. LAA occlusion rates did not differ by index ICH date (P=0.88).

In a contemporary, multicenter US cohort of patients with ICH and AF, 60% were prescribed anticoagulation after discharge, and the remainder were mostly treated with antiplatelet therapy only. These findings suggest widespread use of different secondary stroke prevention strategies in patients with AF and ICH.