Restarting Anticoagulant Treatment After Intracranial Haemorrhage in Patients With Atrial Fibrillation and the Impact on Recurrent Stroke, Mortality and Bleeding: A Nationwide Cohort Study

Abstract

Background—Intracranial haemorrhage is the most feared complication of oral anticoagulant treatment. The optimal treatment option for atrial fibrillation patients surviving an intracranial haemorrhage remains unknown. We hypothesised that restarting oral anticoagulant treatment was associated with a lower risk of stroke and mortality compared to not restarting.

Methods and Results—Linkage of three Danish nationwide registries in the period between 1997 and 2013 identified atrial fibrillation patients on oral anticoagulant treatment with incident intracranial haemorrhage. Patients were stratified by treatment regimens (no treatment, oral anticoagulant treatment or antiplatelet therapy) post the intracranial haemorrhage. Event rates were assessed 6 weeks after hospital discharge and compared with Cox proportional hazard models. In 1,752 patients (one year of follow-up) the rate of ischemic stroke/systemic embolism and all-cause mortality (per 100 person-years) for oral anticoagulant treatment treated patients were 13.6, compared to 27.3 for non-treated patients and 25.7 for patients receiving antiplatelet therapy. For recurrent intracranial haemorrhage: 8.0 for oral anticoagulant treated, compared to 8.6 for non-treated, and 5.3 for antiplatelet therapy. The adjusted hazard ratio of ischemic stroke/systemic embolism and all-cause mortality was 0.55 (95%CI 0.39-0.78) in patients on oral anticoagulant treatment compared to no treatment. For ischemic stroke/systemic embolism and for all-cause mortality HRs were 0.59 (95%CI 0.33-1.03) and 0.55 (95%CI 0.37-0.82), respectively.

Conclusions—Oral anticoagulant treatment was associated with a significant reduction in ischemic stroke/all-cause mortality rates, supporting oral anticoagulant treatment reintroduction post-intracranial haemorrhage as feasible. Future trials are encouraged to guide clinical practice in these patients. 

Source: circ.ahajournals.org