Restarting oral anticoagulation after intracerebral hemorrhage linked to decreased mortality risk

According to a late-breaking presentation from the International Stroke Conference, resumption of oral anticoagulation after intracerebral hemorrhage was associated with favorable functional outcome and decreased risk for ischemic stroke and mortality.

The resumption of oral anticoagulation treatment after intracerebral hemorrhage is a point of contention, however, the effect of intracerebral hemorrhage location on functional outcome after oral anticoagulation resumption has yet to be fully studied, Alessandro Biffi, MD, from the department of neurology at Massachusetts General Hospital, said in a presentation.

“The issue with oral anticoagulation in intracerebral hemorrhage is related to the fact that approximately 10% to 15% of intracerebral hemorrhages occur in the setting of oral anticoagulation, primarily for prevention of cardioembolic stroke,” Biffi said. “Therefore, resuming or not oral anticoagulation after a major cerebral hemorrhagic event is a conundrum where clinicians and patients and families have to weigh the risks and benefits of hemorrhagic thrombotic events.”

The researchers conducted a meta-analysis using individual patient data from a 542 -patient, multicenter study conducted in Germany; a 268-patient, longitudinal primary intracerebral hemorrhage study at Massachusetts General Hospital; and the 217-patient multicenter ERICH study.

Biffi and colleagues determined the association of oral anticoagulation at 1 year from the index intracerebral hemorrhage with mortality, favorable functional outcome (defined as modified Rankin Scale score of 0 to 3) and recurrent intracerebral hemorrhage and ischemic stroke.

The researchers analyzed two types of intracerebral hemorrhage — lobar and non-lobar —separately using multivariable models, adjusting for intracerebral hemorrhage volume, discharge modified Rankin Scale score and CHADS₂ and HAS-BLED scores.

A total of 28% of those with non-lobar intracerebral hemorrhage (n = 179) and 23% of those with lobar intracerebral hemorrhage (n = 88) resumed oral anticoagulation, Biffi said.

The resumption of oral anticoagulation in either lobar or non-lobar intracerebral hemorrhage was not associated with intracerebral hemorrhage volume, CHADS₂ and HAS-BLED scores. (all P > .2), according to the researchers.

At 1 year, a multivariable analysis showed that oral anticoagulation resumption after non-lobar intracerebral hemorrhage was associated with decreased mortality (adjusted HR = 0.26; 95% CI, 0.17-0.39), decreased stroke (adjusted HR = 0.45; 95% CI, 0.28-0.71) and favorable functional outcome (adjusted HR = 4.41, 95% CI, 2.92-6.67).

The researchers observed similar findings for oral anticoagulation resumption after lobar intracerebral hemorrhage (adjusted HR for mortality = 0.29; 95% CI, 0.2-0.42; adjusted HR for stroke = 0.51; 95% CI, 0.32-0.8; adjusted HR for favorable functional outcome = 4.15; 95% CI, 2.81-6.13).

“These findings do support the need for clinical trials of [oral anticoagulation treatment] resumption incorporating outcome definitions and minding the distinction between lobar and non-lobar [intracerebral hemorrhage] after primary [intracerebral hemorrhage], Biffi said.”– by Dave Quaile

Reference:

Biffi A, et al. LB6. Presented at: International Stroke Conference; Feb. 22-24, 2017; Houston.

Disclosure: Biffi reports no relevant financial disclosures.