Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis

Goeldlin, Martina; Siepen, Bernhard; Mueller, Madlaine; Volbers, Bastian; Z'Graggen, Werner Josef; Bervini, David; Raabe, Andreas; Sprigg, Nikola; Fischer, Urs; Seiffge, David J

doi:10.1177/23969873211061975

Cited by 5 publications

(4 citation statements)

References 47 publications

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“…Although prior AP or warfarin use was associated with mortality and poor outcome in patients with SICH 34 , 35 , the impact of prior DOAC use on in-hospital mortality remains inconclusive 36 , 37 . A nationwide, cross-sectional Japanese analysis showed that prior use of DOAC (DOAC-ICH) was associated with significantly lower in-hospital mortality than prior use of warfarin (vitamin k antagonist (VKA)-ICH)) in SICH 38 .…”

Section: Discussionmentioning

confidence: 99%

Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry

Ueno,

Tokugawa,

Saito

et al. 2024

Sci Rep

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Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30–23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44–4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.

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Section: Discussionmentioning

confidence: 99%

Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry

Ueno,

Tokugawa,

Saito

et al. 2024

Sci Rep

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“…According to some reports, 62,63 prior APT may increase the risk of HE in ICH patients. In a study on the effects of APT on ICH patients during the acute phase, Toyoda et al discovered that APT was a reliable indicator of acute HE (OR 7.67, 95% CI 1.62–36.4), emergent surgical evacuation of hematoma (OR 3.10, 95% CI 1.18–8.15), and acute death (OR 3.10, 95% CI 1.18–8.15) 63 .…”

Section: Effect Of Apt On Ich Outcomementioning

confidence: 99%

“…According to some reports, 62,63 . 63 In that study, APT was found to be an independent predictor of HE in ICH patients, which could be due to long-term APT inhibiting platelet function, resulting in active bleeding.…”

Section: Relationship Between Prior Apt and The Incidence Of Hematoma...mentioning

confidence: 99%

Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage

Liu

Chen

et al. 2023

CNS Neurosci Ther

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Objective Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long‐term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. Methods We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included “antiplatelet,” “intracerebral hemorrhage,” “cerebral microbleeds,” “hematoma expansion,” “recurrent,” and “reinitiate.” Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. Results When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients’ concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case‐by‐case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence‐based medicine evidence is needed in the future. Conclusion This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large‐scale randomized controlled trials are required.

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“…32 ICH expansion is associated with death, 33 which probably explains why people taking an antiplatelet agent until the time of ICH have a higher risk of death and disability than people not taking antithrombotic agents. 34…”

Section: Association Between Antiplatelet Agents and Outcome After In...mentioning

confidence: 99%

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

Al-Shahi Salman,

Greenberg

2023

Stroke

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This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75–0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97–2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients’ predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25–1.03]; P =0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.

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Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis

Cited by 5 publications

References 47 publications

Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry

Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry

Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

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