Risk-benefit profile tips toward resuming anticoagulants after anticoagulation-associated ICH

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Takeaway

  • Resuming anticoagulant therapy after anticoagulation-associated intracranial hemorrhage (ICH) was associated with reduced risk for thromboembolic events without significantly increased risks for recurrence or death.

Why this matters

  • Evidence to guide this practice is limited.

Key results

  • Pooled rate of resuming anticoagulant therapy was 38%; mean/median duration of interruption was 2.5-124 days after ICH.
  • Likelihood higher for patients with prosthetic heart valves vs Afib (relative risk [RR], 2.52; 95% CI, 1.83-3.45), subarachnoid hemorrhage (RR, 1.65; 95% CI, 1.00-2.72), dyslipidemia (RR, 1.23; 95% CI, 1.02-1.49).
  • Resuming anticoagulant therapy did not significantly increase long-term risks for death (pooled RR, 0.60; P=.14) or ICH recurrence (pooled RR, 1.14; P=.57).
  • Patients in whom anticoagulation was resumed were less likely to experience thromboembolic events (pooled RR, 0.31; P<.001>
  • Among subgroup with Afib, resuming anticoagulant therapy reduced long-term risk for death (pooled RR, 0.27; P<.001>

Study design

  • Systematic review and meta-analysis of 12 cohort studies among 3431 adults with anticoagulation-associated ICH who survived acute phase or hospitalization.
  • Main outcomes: long-term mortality, recurrent ICH, thromboembolic events.
  • Funding: Governmental and institutional sources (e.g., Shanghai Health and Family Planning Commission, National Health and Medical Research Council of Australia).

Limitations

  • Lack of randomized trials.
  • Potential residual, unmeasured confounding.
  • Multiple comparisons.