Resuming oral anticoagulation therapy after intracerebral haemorrhage associated with lower mortality risk
Resuming oral anticoagulation therapy after a lobar or nonlobar intracerebral haemorrhage (ICH) is associated with a lower risk of mortality and favourable functional outcome, according to results of a meta-analysis presented at the International Stroke Conference 2017 (ISC 2017) in Houston, Texas, US.
In adjusted multivariate analyses, resumption of oral anticoagulation therapy was associated with decreased mortality risk in both lobar (hazard ratio [HR], 0.29, 95 percent confidence interval [CI], 0.20–0.42; p<0.0001) and nonlobar ICH survivors (HR, 0.26, 95 percent CI, 0.17–0.39; p<0.0001) at 1 year after ICH. [ISC 2017, abstract LB6]
Resumption of oral anticoagulation therapy was also associated with improved functional outcome (modified Rankin scale, 0–3) at 1 year for both lobar (HR, 4.15, 95 percent CI, 2.81–6.13; p<0.0001) and nonlobar ICH patients (HR, 4.41, 95 percent CI, 2.92–6.67; p<0.0001).
A decreased risk of all-cause stroke was also observed in patients with both lobar (HR, 0.51, 95 percent CI, 0.32–0.80; p=0.004) and nonlobar ICH (HR, 0.45, 95 percent CI, 0.28–0.71; p=0.0008), driven primarily by a reduction in the risk of ischaemic stroke (HR, 0.48; p=0.013 and HR, 0.42; p=0.011 in lobar and nonlobar ICH patients, respectively).
For this meta-analysis, researchers led by Dr Alessandro Biffi from the Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, US, acquired data from three studies – the multicentre German RETRACE* study (n=542), the single-centre MGH longitudinal ICH study (n=268), and the multicentre ERICH** study (n=217). Of the 386 lobar ICH patients, 23 percent (n=88) resumed anticoagulation therapy, as did 28 percent of the 641 nonlobar ICH patients (n=179).
Patients included in the analysis were aged ≥18 years at time of confirmed acute ICH with no prior history of ICH and on vitamin K antagonists or novel oral anticoagulants (NOACs) for prevention of cardioembolic stroke due to nonvalvular atrial fibrillation.
“The issue with oral anticoagulation in ICH is related to the fact that approximately 10–15 percent of [ICHs] occur in the setting of oral anticoagulation primarily for prevention of cardioembolic stroke,” said Biffi. “Therefore, [the choice to resume or not resume] oral anticoagulation after a major cerebral haemorrhagic event is a conundrum where clinicians, patients, and families have to weigh the benefits and the risks of haemorrhagic thrombotic events.”
The researchers acknowledged that the observational nature of the study, the short follow-up period, and the small number of patients on NOACs (<5 percent) were limitations, and recommended that clinical trials be conducted to assess the risks and benefits of resuming oral anticoagulation therapy post-ICH.