Early Resumption of Antiplatelet Therapy Is Safe in Patients With ICH

In patients recovering from intracerebral hemorrhage, early resumption of antiplatelet therapy does not increase risk for recurrent hemorrhage.

Resumption of antiplatelet therapy within 30 days following intracerebral hemorrhage (ICH) is not associated with an increased risk for recurrent ICH and is as safe as late antiplatelet resumption, according to a study in Stroke.

Investigators compared safety outcomes between early and late antiplatelet resumption among ICH survivors with use of data from the National Health Insurance Research Database (NHIRD).

Patients aged 20 years or older who were admitted to the hospital for treatment of spontaneous ICH were identified from January 1, 2008, to December 31, 2017. Eligible patients also had medication possession ratio 1 (MPR1) and MPR2 of 50% or higher. MPR1 was determined by dividing the number of days that the antiplatelet therapy was prescribed within 3 months before ICH by 90 days, and MPR2 was calculated by dividing the number of antiplatelet prescription days within 3 months after antiplatelet resumption by 90 days.

The participants were categorized into 2 groups according to the timing of antiplatelet resumption after the index ICH, the early antiplatelet user group (antiplatelet was prescribed within 30 days after the index ICH and was used continuously for longer than 3 months at outpatient visits or pharmacy refills) or the late antiplatelet user group (antiplatelet received from 31 to 365 days after the index ICH).

Our results may help mitigate the concern of early antiplatelet resumption in patients at risk of thromboembolic disease, and help provide evidence on the suitable timing of antiplatelet resumption after ICH.

Recurrent ICH was the primary outcome, and secondary outcomes included all-cause mortality, major hemorrhagic events, major occlusive vascular events, and ischemic stroke (IS). Participants were followed until a primary or secondary outcome event, the end of 1-year follow-up, death, or until December 31, 2018, whichever occurred first.

A total of 1584 patients with ICH were included, 843 (65% men) in the early group and 741 (64% men) in the late group. The early group were older (early vs late: 71.28 [SD, 11.97] vs 70.06 [SD, 11.71] years; P =.0414) and had a higher frequency of acute myocardial infarction (6.17% vs 3.24%; P =.0065) before propensity score matching (PSM).

The early group had a comparable risk of 1-year recurrent ICH before (early vs late: 4.63% vs 3.37%; adjusted hazard ratio [AHR], 1.415; 95% CI, 0.854-2.347) and after PSM (3.12% vs 3.27%; AHR, 0.967; 95% CI, 0.522-1.791), compared with the late group. The 2 groups had a similar cumulative probability of event-free survival for recurrent ICH (P =.9414).

The risk for all-cause mortality (early vs late: 9.17% vs 7.19%; AHR, 1.364; 95% CI, 0.916-2.031), major hemorrhagic events (4.86% vs 6.11%; AHR, 0.780; 95% CI, 0.482-1.260), major occlusive vascular events (8.02% vs 9.12%; AHR, 0.829; 95% CI, 0.567-1.212), and IS (4.80% vs 4.18%; AHR, 1.147; 95% CI, 0.689-1.909) was not significantly different between the groups at 1 year.

Subgroup analysis showed that early group participants without previous cerebrovascular disease had a significantly lower risk of all-cause mortality (AHR, 0.199; 95% CI, 0.054-0.739) and major hemorrhagic events (AHR, 0.090; 95% CI, 0.010-0.797). Early group patients with chronic kidney disease had a lower risk for IS (AHR, 0.065; 95% CI, 0.012-0.364).

Among several study limitations, risk factor data such as lifestyle, laboratory results, smoking, and physical activity, as well as image data, are not available. Also, clinicians may consider the timing of antiplatelet resumption after ICH based on ICH severity and clinical comorbidities to prevent recurrent ICH, and the generalizability of the findings is uncertain.

“Our results may help mitigate the concern of early antiplatelet resumption in patients at risk of thrombo-embolic disease, and help provide evidence on the suitable timing of antiplatelet resumption after ICH,” the study authors wrote.


Liu C-H, Wu Y-L, Hsu C-C, Lee T-H. Early antiplatelet resumption and the risks of major bleeding after intracerebral hemorrhage. Stroke. Published online January 9, 2023. doi: 10.1161/STROKEAHA.122.040500