J Stroke.  2019 May;21(2):195-206. 10.5853/jos.2018.02243.

Anticoagulants in Older Patients with Nonvalvular Atrial Fibrillation after Intracranial Hemorrhage

• Perreault
• Côté R
• White-Guay B
• Dorais M
• Oussaïd E
• Schnitzer

• KMID: 2449897
• DOI: http://doi.org/10.5853/jos.2018.02243

Abstract

BACKGROUND AND PURPOSE
Patients with nonvalvular atrial fibrillation (NVAF) who survive an intracranial hemorrhage (ICH) have an increased risk of ischemic stroke and systemic embolism (IS/SE). We investigated whether starting oral anticoagulants (OACs) among older NVAF patients after an ICH was associated with a lower risk of IS/SE and mortality but offset by an increase in major bleeding.
METHODS
We assembled a patient cohort from the Quebec Régie de l'Assurance Maladie du Québec (RAMQ) and Med-Echo administrative databases. We identified older adults with NVAF from 1995 to 2015. All patients with incident ICH and discharged in community were included. Patients were categorized according to OAC exposure. Outcomes included IS/SE, all-cause mortality, recurrent ICH and major bleeding after a quarantine period of 6 weeks. Crude event rates were calculated at 1-year of follow-up, and Cox proportional hazard models with a time-dependent binary exposure were used to assess adjusted hazard ratios (AHRs).
RESULTS
The cohort of 683 NVAF patients with ICH aged 83 years on average. The rates (per 100 person-years) for IS/SE, death, ICH and major bleeding were 3.3, 40.6, 11.4, and 2.7 for the no OAC group; and 2.6, 16.3, 5.2, and 5.2 for OAC group, respectively. The AHR for IS/SE and death was 0.10 (95% confidence interval [CI], 0.05 to 0.21), 0.43 (95% CI, 0.19 to 0.97) for recurrent ICH and 1.73 (95% CI, 0.71 to 4.20) for major extracranial bleeding comparing OAC exposure to non-exposed.
CONCLUSIONS
Initiating OAC after ICH in older individuals with NVAF is associated with a reduction of IS/SE and mortality and a trend in recurrent ICH supporting its use after ICH.

Keyword

Anticoagulants; Atrial fibrillation; Intracranial hemorrhages

MeSH Terms

Adult
Anticoagulants*
Atrial Fibrillation*
Cohort Studies
Embolism
Follow-Up Studies
Hemorrhage
Humans
Intracranial Hemorrhages*
Mortality
Proportional Hazards Models
Quarantine
Quebec
Stroke
Anticoagulants