Expanded anticoagulant use could explain intracerebral hemorrhage rise in older patients
Between 1985 and 2016, intracerebral hemorrhage increased in prevalence among patients aged at least 75 years, a trend that coincided with a threefold increase in use of anticoagulants.
Elevated BP and statin use were among the factors associated with intracerebral hemorrhage (ICH), researchers reported.
“Given the lack of therapy to treat ICH, emphasis should be placed on prevention, which needs to be optimized and intensified,” Vasileios-Arsenios Lioutas, MD, vascular neurologist at Beth Israel Deaconess Medical Center and Harvard Medical School, and colleagues wrote. “The aging of the population and the more widespread use of anticoagulant medications suggest the need for more precise and accurate risk stratification strategies to mitigate the competing risks of ischemia and hemorrhage, especially in older individuals.”
In an analysis of the Framingham Heart Study published in JAMA Neurology, researchers studied participant and participant offspring follow-up data from 1948 to 2016 to assess ICH incidence stratified by location and to identify location-specific risk factors.
During 68 years of follow-up of 10,333 original and offspring participants, there were 129 patients with ICH (mean age, 77 years; 56% women), for an incidence rate of 43 cases per 100,000 patient-years, the researchers wrote.
Compared with participants aged 45 to 74 years, patients aged 75 to 84 years had elevated risk for ICH between 2000 and 2016 (HR = 5.52; 95% CI, 3.66-8.32), as did patients aged 85 to 99 years (HR = 12.51; 95% CI, 8.14-19.22), according to the researchers.
Among those aged at least 75 years, the incidence rate rose from 88 cases per 100,000 person-years in 1948 to 1986 to 176 cases per 100,000 person-years in 2000 to 2016, Lioutas and colleagues wrote.
Moreover, there was a threefold increase in the use of anticoagulant medications from 1987 to 1999 (4.4%) and 2000 to 2016 (13.9%; RR = 3.28; 95% CI, 1.2-8.95).
“There are several take-home messages. First, the age-adjusted incidence of ICH has stabilized, but not declined, in the last 30 years,” Lioutas told Healio. “Second, the rate has actually increased in those aged older than 75 years. Taking into account that the general population is aging, we should be expecting increased numbers of bleeds in the foreseeable future. Third, there is a contemporaneous threefold increase in the use of anticoagulants, although we could not link this directly to the increased ICH rate in the older age group. Fourth, hypertension is the single most important risk factor for both subtypes of ICH, even for lobar ICH, which has been traditionally linked to cerebral amyloid angiopathy.”
In other findings, elevated systolic (P = .008) and diastolic BP (P = .01) in addition to statin use (OR = 4.07; 95% CI, 1.16-14.21) were associated with incidence of deep ICH.
Higher systolic BP (P = .002) and apolipoprotein E epsilon 4 allele homozygosity (OR = 3.66; 95% CI, 1.28-10.43) were associated with lobar ICH, the researchers wrote.
“One of the major future research studies necessary is replication of our findings in racially and socioeconomically diverse populations,” Lioutas said in an interview. “The studied population from the Framingham Heart Study is almost exclusively white of European ancestry. A second line of research should focus on disentangling the potential relationship between increased anticoagulant use and intracerebral hemorrhage, especially in the older population.”
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