Key result
DOACs are linked to ~34% lower rate of intracerebral hemorrhage compared with VKAs.
Why the study?
Population-wide changes in oral anticoagulant prescriptions and their impact on intracerebral hemorrhage incidence were unclear during the transition from VKAs to DOACs.
Does the transition from vitamin K antagonists to direct oral anticoagulants reduce the incidence of oral anticoagulation-related intracerebral hemorrhage in a general population cohort?
Cohort (n=1,919)
No
Does the transition from vitamin K antagonists to direct oral anticoagulants reduce the incidence of oral anticoagulation-related intracerebral hemorrhage in a general population cohort?
Despite a near-doubling of oral anticoagulant use at the population level, overall intracerebral hemorrhage incidence remained stable as transitioning from VKAs to DOACs was associated with a 53% lower rate of anticoagulant-related intracerebral hemorrhage.
Answers are grounded in this paper and cite their sources.
Supports DOAC preference to lower ICH risk in eligible patients; leaves open causal effects and practice change pending trials.
Background We investigated population-wide changes in prescriptions of oral anticoagulants (OAC) (vitamin K antagonists [VKA]) compared to direct oral anticoagulants (DOAC) and whether these translated into a decline in incidences of OAC-related intracerebral hemorrhages (ICH).Methods This observational study analyzed OAC use in Southern Finland during 2005–2009 (pre-DOAC era) and 2015–2019 (transition-to-DOAC era) based on national registries. From medical records, we identified all non-traumatic ICH patients admitted to our tertiary hospital, the only one admitting neurological emergencies within the region. We compared the impact of DOACs versus VKAs on annual ICH incidence using an adjusted generalized additive model (GAM).Results The total population increased from 1.4 to 1.7 million between 2005 and 2019. The use of OACs increased from 1.65% of the population in 2005–2009 (100% VKA) to 2.97% in 2015–2019 (64% VKA, 36% DOAC), resulting in 368,055 person-years of OAC use. In 2019, DOAC use exceeded VKA use. The annual incidence of ICH was 12/100,000 person-years in both periods. During 2005–2009, 115 (13%) of 917 ICHs were OAC-related (100% VKA) compared to 178 (18%) of 1002 ICHs in 2015–2019 (73% VKA, 27% DOAC). In the GAM, the rate of ICH among patients on DOACs was 53% lower than among patients on VKA (p < 0.001).Conclusions ICH incidence remained stable despite near-doubled OAC use. The lower ICH rates with DOACs compared to VKAs support their safety advantage.
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Tomppo et al. (2026) conducted a cohort in Non-traumatic intracerebral hemorrhage and oral anticoagulant exposure (n=1,919). Direct oral anticoagulants (apixaban, dabigatran, edoxaban, rivaroxaban) vs. Vitamin K antagonists (warfarin) was evaluated on Annual incidence rate of oral anticoagulant-related intracerebral hemorrhage (per 10,000 patients on OACs) (IRR 0.66 (GAM percentage change -52.7%), 95% CI 0.47-0.91, p=0.011 (<0.001 in adjusted GAM)). Direct oral anticoagulants were associated with a 52.7% lower adjusted rate of intracerebral hemorrhage compared with vitamin K antagonists (95% CI -63.0% to -39.6%, p<0.001).
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