Results from a study presented at the 2016 European Society of Cardiology (ESC) congress in Rome suggest that, for at least some patients with atrial fibrillation (AF), oral anticoagulant therapy after a traumatic intracranial hemorrhage (ICH) event may reduce the risk for ischemic stroke and all-cause mortality.

Researchers found that patients with AF had better outcomes when assigned to oral anticoagulants following traumatic ICH or hemorrhagic stroke compared with those who did not restart therapy (see chart). Peter Brønnum Nielsen, PhD, FESC, of Aalborg University Hospital in Denmark, and fellow investigators observed an increase in recurrent ICH that was not statistically significant, and noted a “clear trend” toward a decline in ischemic events associated with oral anticoagulant therapy.

Event rates associated with oral anticoagulant therapy following hemorrhagic stroke or traumatic ICH at 1-year

Hemorrhagic stroke

Oral anticoagulant (%)

No therapy (%)

Ischemic stroke

4.0

8.1

Recurrent ICH

6.9

5.1

All-cause mortality

21.0

34.0

Traumatic ICH

Oral anticoagulant (%)

No therapy (%)

Ischemic stroke

1.9

3.6

Recurrent ICH

7.2

16.4

All-cause mortality

13.7

34.8

Joshua Cooper, MD, director of cardiac electrophysiology at Temple University’s Lewis Katz School of Medicine, reviewed the results for Cardiology Advisor. He said these results needed to be evaluated in a randomized trial, but would cause some cardiologists to change their thinking.

“Many people would have felt that, once a patient had a bleed in the head, he or she could never go back on a blood thinner because they’re proven to be at high risk for bleeding. If you asked 100 cardiologists that question, many of them would automatically hold off putting the patient back on a blood thinner,” he said. “This information reminds everybody the patient continues to have a risk for stroke from clotting. It isn’t simply a one-way street where, once [the patient] bleeds, that’s the only factor to consider. You have to consider the risk of not going back on a blood thinner. This report reminds us that, it may be, in many patients, the risk is higher to be off the blood thinner than to go back on.”

Cardiologists have long debated whether the risk for future bleeding associated with restarting anticoagulant therapy following intracranial hemorrhage or hemorrhagic stroke was balanced by the reduced risk for clotting in patients with AF. Dr Nielsen and fellow researchers  conducted an observational cohort study to explore that question.

Eligible patients (N=2664) who had experienced incident hemorrhagic stroke or traumatic ICH and undergone treatment with dabigatran (3.8%), rivaroxaban (3.0%), or apixaban (1.8%), or a vitamin K antagonist (91.3%). About 6% of patients resumed oral anticoagulant therapy within 14 days of being released from the hospital.

Dr Cooper noted that although the study has limitations, including a highly selective patient population, the results were strong enough to make him reconsider treatment decisions in the future.

“Before this study, I would have looked at the specific circumstances and asked my neurology or neurosurgery colleagues, “What’s this patient’s future risk for bleeding in the head?” he said. “If they felt it was significant, I might hold on anticoagulant treatment or consider an alternative treatment for stroke prevention.

“Now, I might be more comfortable with restarting a blood thinner in a patient who had a bleed and in whom we, together, feel there is a manageable risk of repeat bleed in the future.”

Reference

Nielsen PB, Larsen TB, Skjøth, F, Lip GYH. Outcomes associated with oral anticoagulant treatment post hemorrhagic stroke or traumatic intracranial bleeding: a nationwide cohort study on atrial fibrillation patients. Presented at European Society of Cardiology Congress. August 27-31, 2016; Rome, Italy.