Antiplatelet therapy appears safe after intracerebral hemorrhage

Restarting antiplatelet therapy did not significantly increase the risk for recurrent intracerebral hemorrhage or major vascular events, according to a study in JAMA Neurology.

“After extended follow-up of 537 survivors of stroke due to intracerebral hemorrhage (ICH) that occurred whilst they were taking an antithrombotic drug, RESTART found that starting long-term antiplatelet therapy was unlikely to be harmful and might be beneficial compared to avoiding antiplatelet therapy,” Rustam A. Salman, PhD, from the Center for Clinical Brain Sciences, University of Edinburgh, Scotland, told Healio Neurology.

“Guidelines published in Canada and China after RESTART’s main findings were reported in 2019 concluded that starting antiplatelet therapy may be considered after antithrombotic-associated ICH,” Salman said. “More evidence is required to make a stronger recommendation.”

From May 22, 2013, through May 31, 2018, Salman and colleagues recruited the study cohort from 122 hospitals in the U.K. All patients were aged 18 years or older and had survived at least 24 hours after spontaneous ICH (confirmed by brain imaging) and received antithrombotic therapy for prevention of occlusive vascular disease at the onset of ICH, after which therapy was discontinued. Median patient age was 76 years; most were men (n = 360, 67%); and median time after ICH onset was 76 days.

Investigators randomly assigned patients 1:1 to either start or avoid antiplatelet therapy. The initial follow-up ended on Nov. 30, 2018; however, the annual follow-up was extended to Nov. 30, 2020. Recurrent symptomatic ICH served as the primary outcome, and secondary outcomes included all major vascular events. Researchers followed these outcomes for up to 7 years. They used Cox proportional hazards regression, adjusted for minimization covariates, to assess data.

Investigators reported recurrent intracerebral hemorrhage in 22 of the 268 patients assigned antiplatelet therapy and in 25 of the 268 patients assigned to avoid antiplatelet therapy (adjusted hazard ratio = 0.87; 95%CI, 0.49-1.55).

According to Salman and colleagues, 72 patients assigned to antiplatelet therapy were affected by a major vascular event compared with 87 patients assigned to avoid therapy (HR = 0.79; 95%CI, 0.58-1.08).

“Major vascular events are common after ICH, but antiplatelet therapy might reduce their frequency for people who survive ICH,” Salman said. “In order to confirm the promising findings of the RESTART trial and find out if they apply to all ICH survivors, we hope to obtain funding to perform a definitive main phase trial. This Antiplatelet Secondary Prevention International Randomised trial after INtracerebral hemorrhaGe (ASPIRING) may need to enroll over 4,000 survivors of ICH.”