Anticoagulation Resumption After Intracerebral Hemorrhage

Abstract

Purpose of reviewDecision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH.Recent findingsOAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives.SummaryGiven the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.

<p>When to withhold oral anticoagulation in atrial fibrillation – an overview of frequent clinical discussion topics</p>

“…In patients with a history of ICH and AF, an increasing body of evidence shows the benefits of OAC resumption. However, there is substantial controversy regarding the optimal time period for re-initiation 58–60. A pooled analysis of the retrospective AF studies of Kuramatsu et al, and Nielsen et al, showed that OAC restarters had a lower rate of any thromboembolic event (HR 0.45 [95% CI 0.26–0.78]), and that OAC resumption was not significantly associated with recurrent major bleeding (HR 1.65 [95% CI 0.97–2.79]) 55,61,62.…”

“…In patients with ICH, “early resumption” (within 2 weeks) of OAC therapy in patients with a high risk of thromboembolism, and “late resumption” (after 4 weeks) in patients with a high risk of ICH, has been suggested 60. The most recent European Heart Rhythm Association guidelines recommend that OAC may be restarted after 4–8 weeks after ICH, if the risk of thromboembolism is high and the risk of recurrent ICH is low 9.…”

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“…The anticoagulation resumption is important in patients with mechanical prosthetic valve, AF and CHA 2 DG 2 -VASC score ≥ 3-4 or high risk VTE (6). In these cases the reinitiation of anticoagulation significantly decreases the thromboembolic complication: HR 0.34, 95% CI (35).…”

Complex clinical scenarios with the use of direct oral anticoagulants in patients with atrial fibrillation: a multidisciplinary expert advisory board

“…A recent meta-analysis showed that resuming anticoagulation 4-8 weeks after an intracranial bleed is associated with fewer ischaemic strokes and that there is no increased risk of re-bleeding [25,26]. Currently, a Dutch trial is including patients with a history of AF and a recent intracerebral haemorrhage during treatment with anticoagulation (APACHE-AF, clinicaltrials.gov: NCT02565693).…”