Key result
DOAC-related intracerebral hemorrhage was associated with a lower likelihood of severe ICH compared to VKA-related ICH (17.0% vs 36.8%; OR 0.34, 95% CI 0.13-0.87, p=0.025).
Why the study?
Do DOACs reduce baseline hematoma volume and neurologic deficit severity compared to VKAs in patients with NVAF who develop intracerebral hemorrhage?
Cohort (n=161)
Yes
Do DOACs reduce baseline hematoma volume and neurologic deficit severity compared to VKAs in patients with NVAF who develop intracerebral hemorrhage?
Odds Ratio: 0.34 (95% CI 0.13–0.87)
Absolute Event Rate: 17% vs 36.8%
p-value: p=0.025
In patients with NVAF who develop intracerebral hemorrhage, prior use of DOACs is associated with smaller hematoma volumes and less severe neurologic deficits at admission compared to VKAs.
May indicate milder DOAC-ICH in NVAF; hypothesis-generating and should not yet alter anticoagulation decisions.
Objective: To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). Methods: We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH. Results: We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6–21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA₂DS₂-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3–14] vs 15 [7–25] points, p = 0.003), median baseline hematoma volume (12.8 [4–40] vs 24.3 [11–58.8] cm³, p = 0.007), and median ICH score (1 [0–2] vs 2 [1–3] points, p = 0.049). Severe ICH (>2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13–0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = −0.57, 95% CI −1.02 to −0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21–0.91, p = 0.030). Conclusions: DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH.
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Tsivgoulis et al. (2017) conducted a cohort in Intracerebral hemorrhage related to anticoagulants for nonvalvular atrial fibrillation (n=161). Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs) was evaluated on Severe intracerebral hemorrhage (>2 points on ICH score) (OR 0.34, 95% CI 0.13-0.87, p=0.025). DOAC-related intracerebral hemorrhage was associated with a lower likelihood of severe ICH compared to VKA-related ICH (17.0% vs 36.8%; OR 0.34, 95% CI 0.13-0.87, p=0.025).
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