Key result
OAC cuts ischemic stroke ~77% in AF with prior ICH but increases recurrent ICH.
Why the study?
Although oral anticoagulation effectively reduces stroke risk in atrial fibrillation, its use after intracranial haemorrhage remains controversial due to bleeding concerns.
Does oral anticoagulation reduce ischaemic stroke and recurrent ICH in patients with atrial fibrillation and a history of intracranial haemorrhage?
Meta-Analysis (n=653)
Does oral anticoagulation reduce ischaemic stroke and recurrent ICH in patients with atrial fibrillation and a history of intracranial haemorrhage?
Relative Risk: 0.23 (95% CI 0.06–0.91)
In patients with AF and prior ICH, oral anticoagulation reduces ischaemic stroke but increases recurrent ICH and major haemorrhage, with no significant difference in net clinical benefit.
OAC reduces ischemic stroke but raises recurrent ICH risk in AF after ICH; leaves open net clinical benefit and optimal patient selection.
BACKGROUND: Oral anticoagulation (OAC) effectively reduces stroke risk in patients with atrial fibrillation (AF), but its use after intracranial haemorrhage (ICH) remains controversial due to bleeding concerns. This study aimed to update the evidence on the efficacy and safety of OAC in patients with AF with a history of ICH. METHODS: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched PubMed, Scopus and EMBASE for randomised controlled trials (RCTs) comparing OAC versus avoiding anticoagulation in patients with AF post-ICH. The primary outcomes were ischaemic stroke and recurrent ICH. Secondary outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), major haemorrhage and a composite endpoint of 'net clinical benefit' (first incident ischaemic stroke and first incident recurrent ICH). Pooled risk ratios (RRs) with 95% CIs were calculated using a random-effects model. RESULTS: Four RCTs with 653 participants were included. Anticoagulation was associated with a reduced risk of ischaemic stroke (RR 0.23, 95% CI 0.06 to 0.91) and increased risk of recurrent ICH (RR 3.60, 95% CI 1.40 to 9.30). No significant differences were observed in all-cause mortality (RR 0.93, 95% CI 0.59 to 1.46), cardiovascular death (RR 1.01, 95% CI 0.32 to 3.18) and for net clinical benefit (RR 0.72, 95% CI 0.42 to 1.24). Anticoagulation was associated with a significant increased risk of any major haemorrhage (RR 2.49, 95% CI 1.29 to 4.81) and reduced MACE (RR 0.64, 95% CI 0.44 to 0.94). CONCLUSIONS: OAC in patients with AF and prior ICH was associated with a reduced risk of ischaemic stroke and an increased risk of recurrent ICH. PROSPERO REGISTRATION NUMBER: CRD42025637606.
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D’Anna et al. (2025) conducted a meta-analysis in atrial fibrillation with a history of intracranial haemorrhage (n=653). Oral anticoagulation vs. no anticoagulation was evaluated on ischaemic stroke and recurrent ICH (RR 0.23 for ischaemic stroke; RR 3.60 for recurrent ICH, 95% CI 0.06 to 0.91 for ischaemic stroke; 1.40 to 9.30 for recurrent ICH). Oral anticoagulation in patients with AF and prior ICH reduced ischaemic stroke (RR 0.23; 95% CI 0.06-0.91) but increased recurrent ICH (RR 3.60; 95% CI 1.40-9.30).
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