Effect of oral anticoagulant therapy on adverse outcomes in patients with atrial fibrillation after intracranial hemorrhage

BACKGROUND: The optimal management of oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF) after intracerebral hemorrhage (ICH) remains uncertain. Although recent randomized controlled trials (RCTs) have investigated this clinical dilemma, findings have been inconclusive. OBJECTIVE: To evaluate the efficacy and safety of restarting OACs in patients with AF after ICH, we conducted a meta-analysis of RCTs. METHODS: We conducted a literature search in PubMed, Embase, and the Cochrane Central Register of Controlled Trials, identifying eligible RCTs from inception to March 2025. The primary outcomes were recurrent ICH and stroke or systemic embolism. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model. RESULTS: Three RCTs (Apixaban After Anticoagulation-Associated Intracerebral Haemorrhage in Patients With Atrial Fibrillation, Start or Stop Anticoagulants Randomised Trial, and Prevention of Stroke in Intracerebral Haemorrhage Survivors With Atrial Fibrillation), comprising a total of 623 patients with a median follow-up of 1.2-1.9 years, were included. Most patients received direct OACs. Compared with non-OAC therapy, OAC resumption was associated with a significantly increased risk of recurrent ICH (RR 3.32, 95% CI 1.28-8.61) and major bleeding (RR 3.33, 95% CI 1.54-7.22), without a significant reduction in stroke or systemic embolism (RR 0.68, 95% CI 0.38-1.23). No significant differences were observed in ischemic stroke, major vascular events, all-cause mortality, or cardiovascular mortality. CONCLUSION: In patients with AF with previous ICH, restarting OAC therapy is associated with increased risks of recurrent ICH and major bleeding, without a corresponding reduction in thromboembolic events or all-cause mortality.