Key result
Observational data suggest that resuming oral anticoagulation after intracerebral hemorrhage reduces thromboembolic complications and mortality without significantly increasing the risk of recurrent hemorrhage.
Why the study?
Randomized trial evidence was lacking on whether and when intracerebral hemorrhage survivors should resume oral anticoagulation.
Does resumption of oral anticoagulation reduce thromboembolic complications and mortality without increasing recurrent hemorrhage in survivors of spontaneous intracerebral hemorrhage?
Does resumption of oral anticoagulation reduce thromboembolic complications and mortality without increasing recurrent hemorrhage in survivors of spontaneous intracerebral hemorrhage?
Observational data suggest that resuming oral anticoagulation after intracerebral hemorrhage is beneficial and safe, though definitive guidance awaits the results of ongoing randomized trials.
Supports individualized resumption decisions after ICH; leaves open confirmation from ongoing randomized trials.
BACKGROUND: Given an ageing population the incidence of both patients suffering from intracerebral hemorrhage (ICH) and those requiring oral anticoagulation will increase. Up to now there are no results from randomized trials available whether or not, and when, ICH survivors should resume OAC. This review summarizes the most important observational studies, and initiated ongoing trials, to help guiding physicians in daily routine decision making. FINDINGS: Several large observational studies and meta-analyses verified that OAC resumption was associated with a significant reduction of thromboembolic complications and mortality without leading to increased rates of recurrent ICH. OAC resumption seemed further associated with improved functional recovery and favorable long-term outcome. Given the general bleeding risk reduction in patients using Non-vitamin K antagonist oral anticoagulants (NOAC) compared to Vitamin-K-antagonist (VKA), NOAC use should also be preferred after ICH, although specific comparative studies are pending. Patients with lobar ICH need special attention as these patients showed increased ICH recurrence rates, why decision making should include extended diagnostic work-up evaluating cerebral microbleed burden, cortical subarachnoid hemorrhage and superficial siderosis. Further, patients with mechanical heart valves need specific consideration as restarting VKA may be unsafe until two weeks, whereas optimal balancing of hemorrhagic with thromboembolic complications may allow earlier re-initiation one week after ICH. In patients with atrial fibrillation, resumption generally should take place between 4 and 8 weeks after ICH depending on a patient's individual risk profile. Left atrial appendage occlusion (LAAO) might represent an alternative strategy in high-risk patients. Ongoing clinical trials will clarify whether OAC resumption versus LAAO versus no antithrombotic therapy may represent the best possible secondary stroke prevention in ICH survivors with atrial fibrillation. CONCLUSIONS: According to observational data OAC resumption after ICH seems beneficial and safe. Ongoing clinical trials will create evidence regarding treatment effects of pharmaceutical resumption and interventional alternatives. Yet, individual decision making weighing the patient's individual thromboembolic versus hemorrhagic risks remains essential.
No takes yet. Share an insight, caveat, or question.
Sembill et al. (2019) conducted a review in Intracerebral hemorrhage with indication for oral anticoagulation. Resumption of oral anticoagulation vs. No antithrombotic therapy or antiplatelet therapy was evaluated. Observational data suggest that resuming oral anticoagulation after intracerebral hemorrhage reduces thromboembolic complications and mortality without significantly increasing the risk of recurrent hemorrhage.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: