Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials

Al-Shahi Salman, Rustam; Stephen, Jacqueline; Tierney, Jayne F; Lewis, Steff C; Newby, David E; Parry-Jones, Adrian R; White, Philip M; Connolly, Stuart J; Benavente, Oscar R; Dowlatshahi, Dar; Cordonnier, Charlotte; Viscoli, Catherine M; Sheth, Kevin N; Kamel, Hooman; Veltkamp, Roland; Larsen, Kristin T; Hofmeijer, Jeannette; Kerkhoff, Henk; Schreuder, Floris H B M; Shoamanesh, Ashkan; Klijn, Catharina J M; van der Worp, H Bart; Klug, Didier; Casolla, Barbara; Puy, Laurent; Coffee, Morgane; Kuchcinski, Grégory; Labreuche, Julien; van Nieuwenhuizen, Koen M.; Algra, Ale; van Gelder, Isabelle C.; Kappelle, L. Jaap; Rinkel, Gabriel J.E.; Schutgens, Roger E.G.; Khatri, Pooja; Conwit, Robin; Falcone, Guido; Elm, Jordan; Anderson, Craig S.; Song, Lili; Pandian, Jeyaraj; Hart, Robert G.; Sharma, Mukul; Aref, Hany; Tarhuni, Wadea; Fabregas, Joan Marti; Diener, Hans-Christoph; Endres, Matthias; Lemmens, Robin; Kwon, Sun U.; Lee, Byung-Chul; Ameriso, Sebastian; Milling, Truman J.; Kasner, Scott E.; Mikulik, Robert; Xavier, Denis; Beer, Ronny; Toni, Danilo; Eckstein, Jens; Seiffge, David; Ferro, Jose M.; Tsivgoulis, Georgios; Sharma, Sanjib K.; Wei-Liou, Chia; Hohnloser, Stefan H.; Katsanos, Aristeidis; Bosch, Jackie; Healey, Jeff; Eikelboom, John; Khaw, Alexander; Gladstone, David; Pikula, Aleksandra; Coutts, Shelagh; Smith, Eric E.; Butcher, Ken; Field, Thalia; Gioia, Laura; Stapf, Christian; Halse, Omid; Ringleb, Peter; Enzinger, Christian; Sibon, Igor; Montaner, Joan; Caso, Valeria; Heuschmann, Peter; Lip, Gregory Y.H.; Haefeli, Walter; Debette, Stefanie; Dennis, Martin S.; Wyller, Torgeir Bruun; Rønning, Ole M.; Eilertsen, Helle; Ihle-Hansen, Hege; Sandset, Else Charlotte; Pennlert, Johanna; Glader, Eva-Lotta; Kruuse, Christina; Wester, Per; Carlsson, Maria; Forfang, Elisabeth

doi:10.1016/s1474-4422(23)00315-0

Cited by 10 publications

(2 citation statements)

References 26 publications

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“…Regarding randomized clinical trials, the evidence on the timing of resumption of OAT after ICH in patients with AF comes from four prospective randomized controlled clinical trials, the subject of a recent meta-analysis. 15 Three studies were specifically dedicated to patients with AF and ICH, the Start or Stop Anticoagulants Randomized Trial (SoSTART) study with 203 participants, the Apixaban vs. Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intracerebral haemorrhage in patients with Atrial Fibrillation (APACHE-AF) study with 101 participants, the Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation and previous Intracerebral Haemorrhage (NASPAF-ICH) study with 30 participants, and the Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDECARE-AF) study which included a subgroup of 80 patients with AF and previous ICH. The intervention arm was a DOAC in 209 of 212 patients assigned to start OAT, and the control arm was antiplatelet therapy in 67 (33%) of 200 patients assigned to avoid OAT.…”

Section: Anticoagulant Therapy After Intracranial Haemorrhage In Pati...mentioning

confidence: 99%

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Vassiliki’ Coutsoumbas,

Di Pasquale

2024

European Heart Journal Supplements

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Intracranial haemorrhage (ICH) is the most feared haemorrhagic complication of oral anticoagulant therapy (OAT), although the risk is significantly lower with direct oral anticoagulants (DOACs) compared with warfarin. Intracranial haemorrhage is generally considered, by clinicians, to be an absolute contraindication to starting or resuming OAT in patients with atrial fibrillation (AF). On the other hand, the pivotal trials with DOACs excluded patients with previous ICH. Observational studies actually indicate a net clinical benefit in favour of DOAC in patients with AF and previous ICH. This benefit is confirmed by randomized clinical trials which, however, have the limitation of the small number of cases, but larger clinical trials comparing DOACs vs. aspirin or no therapy are underway. While OAT is certainly contraindicated in patients with lobar ICH and cerebral amyloid angiopathy, in other cases, the decision must be made in the individual patient through an accurate balance between thromboembolic risk and haemorrhagic risk and a multidisciplinary cardio-neurological evaluation.

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Section: Anticoagulant Therapy After Intracranial Haemorrhage In Pati...mentioning

confidence: 99%

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Vassiliki’ Coutsoumbas,

Di Pasquale

2024

European Heart Journal Supplements

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“…Further large-scale studies with long-term follow-up are needed to determine the indications for resuming DOACs in AF patients with ICH as well as the optimal timing of resumption and the optimal type of agent. A recent meta-analysis of 412 patients with AF and ICH from four randomized trials reported that initiating oral anticoagulation reduced the risk of stroke or cardiovascular death [ 40 ]. Ongoing randomized and observational clinical trials will hopefully provide more data in the future ( Table 2 ).…”

Section: Anticoagulationmentioning

confidence: 99%

Cardioembolic Stroke: Past Advancements, Current Challenges, and Future Directions

Kato,

Tsutsui,

Nakano

et al. 2024

IJMS

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Cardioembolic stroke accounts for over 20% of ischemic strokes and is associated with worse outcomes than other types of strokes. Atrial fibrillation (AF) is the most common risk factor for cardioembolic stroke. In this narrative review, we present an update about cardioembolic stroke mainly related to AF and atrial cardiopathy. Direct oral anticoagulants (DOACs) have revolutionized stroke prevention in patients with AF; however, their efficacy in preventing recurrent embolic stroke of unknown source remains uncertain. Various cardiac monitoring methods are used to detect AF, which is crucial for preventing stroke recurrence. DOACs are preferred over warfarin for AF-related stroke prevention; however, the timing of initiation after acute ischemic stroke is debated. Resuming anticoagulation after intracerebral hemorrhage in AF patients requires careful assessment of the risks. While catheter ablation may reduce the incidence of cardiovascular events, its effect on stroke prevention is unclear, especially in heart failure patients. Atrial cardiopathy is the emerging cause of embolic stroke of unknown source, which indicates atrial structural and functional disorders that can precede AF. Future research should focus on refining stroke risk prediction models, optimizing AF detection, understanding the roles of ablation and anticoagulation in stroke prevention, and establishing atrial cardiopathy as a therapeutic target, which could significantly reduce the burden of stroke.

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Real-World Management Strategies of Anticoagulated Atrial Fibrillation Patients After a Clinically Significant Bleeding Episode

Brouillard,

Diallo,

Masson

et al. 2024

Canadian Journal of Cardiology

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Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials

Cited by 10 publications

References 26 publications

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Cardioembolic Stroke: Past Advancements, Current Challenges, and Future Directions

Real-World Management Strategies of Anticoagulated Atrial Fibrillation Patients After a Clinically Significant Bleeding Episode

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