What is the clinical evidence from this study?

Study design: Review. Population: Intracerebral hemorrhage. Intervention: Oral anticoagulant resumption vs. No oral anticoagulant resumption.

May 20, 2018Open Access

Anticoagulation Resumption After Intracerebral Hemorrhage

Key Result

Resumption of oral anticoagulants after intracerebral hemorrhage does not increase the risk of recurrent hemorrhage and reduces the risk of thromboembolism and all-cause mortality.

Structured PICO

Does resumption of oral anticoagulants reduce thromboembolism and mortality without increasing recurrent intracerebral hemorrhage in patients after an intracerebral hemorrhage?

Population

Patients with intracerebral hemorrhage (ICH) who have an indication for oral anticoagulation

Intervention

Resumption of oral anticoagulants (OAC) or left atrial appendage closure

Comparator

Cessation of oral anticoagulants

Outcome

Recurrent intracerebral hemorrhage and thromboembolismhard clinical

Resuming oral anticoagulation after intracerebral hemorrhage appears to reduce thromboembolism and mortality without increasing recurrent bleeding, though optimal timing remains unclear and requires individualized assessment.

Limitations

Lack of high-quality evidence from randomized clinical trials to guide clinical decision-making
Observational nature of the available studies regarding oral anticoagulant resumption
Selection bias in observational studies where patients with less severe intracerebral hemorrhage often restart anticoagulation earlier

Abstract

PURPOSE OF REVIEW: Decision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH. RECENT FINDINGS: OAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early ( 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives. Given the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.

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