Apixaban Versus Rivaroxaban After Spontaneous Intracranial Hemorrhage in Atrial Fibrillation: A Propensity Score-Matched TriNetX Study

Background Survivors of spontaneous intracranial hemorrhage (ICH) with atrial fibrillation (AF) face competing risks of thromboembolism and recurrent bleeding. Evidence directly comparing individual direct oral anticoagulants after resumption is limited. Methods Using the TriNetX Global Collaborative Network, we conducted a retrospective cohort study of adults with AF who restarted apixaban or rivaroxaban after spontaneous ICH. The index date was DOAC resumption, and cohorts were matched 1:1 using propensity scores. Recurrent spontaneous ICH was assessed at 30, 90, 180, and 365 days. One-year secondary outcomes were ischemic stroke, all-cause mortality, major bleeding, and gastrointestinal bleeding. Cox models produced hazard ratios (HRs) with 95% confidence intervals, with log-rank testing. Results At 1 year, recurrent spontaneous ICH occurred in 141 (34.9%) apixaban-treated and 135 (33.4%) rivaroxaban-treated patients (HR 1.076, 95% CI 0.850-1.363; P = 0.542). No significant differences were detected at 30, 90, or 180 days. One-year ischemic stroke (HR 1.109, 95% CI 0.863-1.424), all-cause mortality (HR 1.336, 95% CI 0.937-1.903), major bleeding (HR 1.074, 95% CI 0.861-1.339), and gastrointestinal bleeding (HR 1.480, 95% CI 0.844-2.597) also did not differ. A day 31-365 sensitivity analysis was consistent (HR 1.02, 95% CI 0.77-1.36; P = 0.868) . Conclusions In this propensity score-matched real-world cohort, no statistically significant differences were detected between apixaban and rivaroxaban for recurrent spontaneous ICH or major clinical outcomes after anticoagulation resumption. These findings concern the choice of agent among patients in whom resumption has already been decided; anticoagulation after spontaneous ICH remains an unproven strategy, and enrolment in randomized trials is preferred where available.