Intracranial hemorrhage in patients with atrial fibrillation receiving anticoagulation therapy

Abstract

Key Points• Nearly 80% of the warfarintreated patients with ICH had an INR within or below therapeutic range around 2 weeks before the event.• We can reduce ICH by using apixaban rather than warfarin and by avoiding concomitant aspirin, especially in patients with older age.We investigated the frequency and characteristics of intracranial hemorrhage (ICH), the factors associated with the risk of ICH, and outcomes post-ICH overall and by randomized treatment. We identified patients with ICH from the overall trial population enrolled in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial who received ‡1 dose of the study drug (n 5 18 140). ICH was adjudicated by a central committee. Cox regression models were used to identify factors associated with ICH. ICH occurred in 174 patients; most ICH events were spontaneous (71.7%) versus traumatic (28.3%). Apixaban resulted in significantly less ICH (0.33% per year), regardless of type and location, than warfarin (0.80% per year). Independent factors associated with increased risk of ICH were enrollment in Asia or Latin America, older age, prior stroke/transient ischemic attack, and aspirin use at baseline. Among warfarin-treated patients, the median (25th, 75th percentiles) time from most recent international normalized ratio (INR) to ICH was 13 days (6, 21 days). Median INR prior to ICH was 2.6 (2.1, 3.0); 78.5% of patients had a pre-ICH INR <3.0. After ICH, the modified Rankin scale score at discharge was ‡4 in 55.7% of patients, and the overall mortality rate at 30 days was 43.3% with no difference between apixaban-and warfarin-treated patients. ICH occurred at a rate of 0.80% per year with warfarin regardless of INR control and at a rate of 0.33% per year with apixaban and was associated with high short-term morbidity and mortality. This highlights the clinical relevance of reducing ICH by using apixaban rather than warfarin and avoiding concomitant aspirin, especially in patients of older age. This trial was registered at www.clinicaltrials.gov as

Idarucizumab for Dabigatran Reversal — Full Cohort Analysis

“…The 30-day mortality rate observed in this study is lower than the 30-day mortality rate of 50% observed among patients who were receiving warfarin and presented with intracranial hemorrhage and than the 30-day mortality rate of 30% observed among patients who were receiving warfarin and were about to undergo emergency intervention. [12][13][14][15][16][17] However, it is similar to the 30-day mortality rate of 15% observed among the first 67 patients enrolled in a study of andexanet for the reversal of factor Xa inhibitors in patients with serious bleeding. 18 The rate of thrombotic events was 4.8% at 30 days and 6.8% at 90 days, and the 30-day rate was similar in group A and group B (5.0% and 4.6%, respectively).…”

Guideline‐concordant initiation of oral anticoagulant therapy for stroke prevention in older veterans with atrial fibrillation eligible for Medicare Part D

“…Consistent with this hypothesis, in our sample, patients with higher bleeding risk were less likely to initiate anticoagulation. Nevertheless, evidence shows that providers often overestimate the risk of intracranial hemorrhage among AF patients . In one observational study among Medicare beneficiaries with AF at high risk of falls, ischemic stroke was nearly five times more common than intracranial hemorrhage .…”

“…Nevertheless, evidence shows that providers often overestimate the risk of intracranial hemorrhage among AF patients. 42 In one observational study among Medicare beneficiaries with AF at high risk of falls, ischemic stroke was nearly five times more common than intracranial hemorrhage. 43 Increasing provider education on incidence of intracranial hemorrhage during OAC therapy is therefore likely to increase initiation of these drugs in AF patients.…”

Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation

“…43 Nearly 80% of patients who suffer from an ICH on VKA therapy do so with a therapeutic INR (INR < 3.0). 44 Risk factors for ICH on OAC include VKA use, prior stroke/TIA and age. 44 Concomitant antiplatelet therapy is also a strong risk factor for ICH, underscoring the importance of discontinuing aspirin if not indicated.…”

“…44 Risk factors for ICH on OAC include VKA use, prior stroke/TIA and age. 44 Concomitant antiplatelet therapy is also a strong risk factor for ICH, underscoring the importance of discontinuing aspirin if not indicated. 44 Data from the Medicare administrative claims database found that elderly patients deemed at risk for falls have elevated risk for ICH (HR, 1.9; 95% CI, 1.3-2.9).…”