Anticoagulation Therapy Following Intracranial Hemorrhage in Atrial Fibrillation

Researchers examined the effect of anticoagulation therapy in patients with atrial fibrillation on risk for severe thrombotic events and severe hemorrhage events.

Among patients with atrial fibrillation who recently survived intracranial hemorrhage, resuming anticoagulation and antiplatelet therapy decreased severe thrombotic events (STEs) and severe hemorrhage events (SHEs), according to study findings published in the International Journal of Cardiology Heart and Vasculature.

Researchers sought to investigate the risks of anticoagulation treatment for STEs and SHEs in patients with atrial fibrillation (AF), and to compare the effect of novel direct oral anticoagulants (NOACs) with warfarin among these patients. The primary endpoints were STEs and SHEs.

To accomplish this, they conducted a retrospective observational cohort study of Korean national health insurance claims from the Korean Health Insurance and Review Assessment (HIRA) from January 2002 through December 2017 of patients with AF who survived a recent ICH with follow-up through December 2017. Of 4964 patients (aged 63.83±12.59 years; 45% women) analyzed, 17.7% were treated with anticoagulant therapy and 41.7% were treated with antiplatelet therapy.

Anticoagulant users (hazard ratio [HR] for STE, 0.385; 95% CI, 0.312-0.475; P <.0001; HR for SHE, 0.578; 95% CI, 0.487-0.685; P <.0001) and antiplatelet users (HR for STEs, 0.545; 95% CI, 0.474-0.625; P <.0001; HR for SHEs, 0.637; 95% CI, 0.563-0.720; P <.0001) compared with non-antithrombotic users had lower risk for STEs and SHEs. Six to 8 weeks following ICH, the anticoagulation cohort had the lowest risk of all-cause death (HR, 0.614; 95% CI, 95% CI, 0.372-1.011, P =.0552), although anticoagulant and antiplatelet users displayed no risk difference. NOACs compared with warfarin more effectively reduced the risk for STEs (HR, 0.263; 95% CI, 95% CI, 0.144-0.480; P <.0001).

Study limitations included significant data lacking in the HIRA database, lack of statistical validity, and the theoretical definitions of STEs and SHEs do not match real-world events. Also, patients with contraindications to anticoagulants were not identified, the extent of disability among patients experiencing STEs and SHEs was not accounted for, and there was lack of study population heterogeneity.

Among patients with AF who survived an ICH, researchers stated that, “resumption of anticoagulant was associated with a greater reduction in the STEs and SHEs as compared with resumption of antiplatelet usage or no treatment.” Fewer thrombotic events occurred among patients treated with NOACs compared with patients treated with warfarin.


Moon JY, Bae GH, Jung J, Shin D. Restarting anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation: A nationwide retrospective cohort study. Int J Cardiol Heart Vasc. Published online April 26, 2022.