Post‐Intracranial Hemorrhage Antithrombotic Therapy in Patients With Atrial Fibrillation

Lin, Shu; Chang, Yu‐Chen; Lin, Fang‐Ju; Tang, Sung‐Chun; Dong, Yaa‐Hui; Wang, Chi‐Chuan

doi:10.1161/jaha.121.022849

Cited by 11 publications

(35 citation statements)

References 27 publications

(44 reference statements)

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“…(29). Data from the present studies demonstrated superior effectiveness and safety outcomes of NOAC in stroke or systemic embolism and recurrent ICH compared with VKA, which was consistent with associated RCTs and observational cohorts in AF patients with previously diagnosed ICH (11,(23)(24)(25). A prior meta-analysis, which pooled 48 randomized trials and 71,683 patients with AF, suggested that the superior effectiveness and safety profiles of NOAC were attributed to the prevention of stroke, which included ICH and ischemic stroke (8).…”

Section: Discussionsupporting

confidence: 86%

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Liu

Guo

2022

Front. Cardiovasc. Med.

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BackgroundIntracranial hemorrhage (ICH) is excluded in most anticoagulation randomized clinical trials (RCTs), so oral anticoagulant (OAC) therapy is still the conventional treatment for patients with atrial fibrillation (AF) after ICH. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of OAC for these patients.MethodsWe systematically searched the PubMed and Embase databases up to March 2022 for RCTs and observational studies exploring the effect of OAC in patients with AF after ICH. The effectiveness outcomes included stroke or systemic embolism, ischemic stroke, and all-cause death, whereas the safety outcomes were major bleeding and recurrent ICH. Hazard ratios (HRs) and 95% confidence intervals (CIs) from each study were pooled using a random-effects model.ResultsA total of 14 studies were included. The OAC therapy that was performed reduced the risks of stroke or systemic embolism (HR = 0.65, 95% CI 0.53–0.81), ischemic stroke (HR = 0.70, 95% CI 0.60–0.82), and all-cause death (HR = 0.43, 95% CI 0.27–0.70) but had a higher risk of major bleeding (HR = 1.50, 95% CI 0.94–2.40) and showed no difference in recurrent ICH (HR = 0.91, 95% CI 0.53–1.55) compared to the no OAC therapy. With the use of non-vitamin K antagonist oral anticoagulant (NOAC) therapy, a lower risk of stroke or systemic embolism (HR = 0.83, 95% CI 0.70–0.98), all-cause death (HR = 0.67, 95% CI 0.53–0.84), and recurrent ICH (HR = 0.68, 95% CI 0.54–0.86) was observed against the use of vitamin K antagonists (VKA) therapy.ConclusionThe OAC therapy (especially VKA) revealed superior effectiveness in patients with AF after ICH, and the superiority of NOAC was also found, but some related evidence was limited.

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Section: Discussionsupporting

confidence: 86%

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Liu

Guo

2022

Front. Cardiovasc. Med.

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“…Nine publications ( Nielsen et al, 2015 ; Chao et al, 2016 ; Nielsen et al, 2017 ; Lee et al, 2020 ; Newman et al, 2020 ; Tsai et al, 2020 ; Schreuder et al, 2021 ; SoSTART Collaboration, 2021 ; Lin et al, 2022 ) included 17,781 patients. Seven studies compared the effectiveness and safety of starting OAC and non-OAC after ICH in AF patients ( Nielsen et al, 2015 ; Chao et al, 2016 ; Nielsen et al, 2017 ; Newman et al, 2020 ; Schreuder et al, 2021 ; SoSTART Collaboration, 2021 ; Lin et al, 2022 ). Three studies compared the effectiveness and safety of warfarin and DOACs ( Lee et al, 2020 ; Tsai et al, 2020 ; Lin et al, 2022 ).…”

Section: Resultsmentioning

confidence: 99%

“…Seven studies compared the effectiveness and safety of starting OAC and non-OAC after ICH in AF patients ( Nielsen et al, 2015 ; Chao et al, 2016 ; Nielsen et al, 2017 ; Newman et al, 2020 ; Schreuder et al, 2021 ; SoSTART Collaboration, 2021 ; Lin et al, 2022 ). Three studies compared the effectiveness and safety of warfarin and DOACs ( Lee et al, 2020 ; Tsai et al, 2020 ; Lin et al, 2022 ). Lin SY et al compared the effectiveness and safety of starting OAC and non-OAC, as well as warfarin and DOACs.…”

Section: Resultsmentioning

confidence: 99%

“…Lin SY et al compared the effectiveness and safety of starting OAC and non-OAC, as well as warfarin and DOACs. Our studies included two RCTs ( Schreuder et al, 2021 ; SoSTART Collaboration, 2021 ), one prospective cohort study ( Tsai et al, 2020 ), and six retrospective cohort studies ( Nielsen et al, 2015 ; Chao et al, 2016 ; Nielsen et al, 2017 ; Lee et al, 2020 ; Newman et al, 2020 ; Lin et al, 2022 ). The follow-up period ranged from 0.5 to 3 years Table 1 illustrates the main study characteristics of the publications.…”

Section: Resultsmentioning

confidence: 99%

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Efficacy and safety of anticoagulation in atrial fibrillation patients with intracranial hemorrhage: A systematic review and meta-analysis

Zhou

Liu²,

Yang

et al. 2023

Front. Pharmacol.

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Background: The benefits and risks of starting anticoagulation therapy, such as direct oral anticoagulations (DOACs) or warfarin, in atrial fibrillation (AF) patients with a history of intracranial hemorrhage (ICH) remain controversial. We performed a systematic review and meta-analysis to compare the safety and efficacy of starting oral anticoagulation (OAC) and non-oral anticoagulation in these patients.Methods: PubMed, Cochrane Library, and Embase were searched from inception to 01 May 2022 for randomized controlled trials and cohort studies, reporting effectiveness and safety outcomes for anticoagulation therapy in atrial fibrillation patients with intracranial hemorrhage. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration tool were used to evaluate bias risks for all randomized controlled trials (RCTs) and cohort studies. An effects model was applied to calculate adjusted hazard ratios (aHRs) for randomized controlled trials and cohort studies.Results: We analyzed data from two randomized controlled trials (304 patients) and seven Cohort studies (17,477 patients). Compared to non-oral anticoagulation, starting oral anticoagulation therapy reduced the risk of Ischemic Stroke/Systemic Embolism (SE) (aHR: 0.64, 95% CI: 0.55–0.57) and all-cause death (aHR: 0.53, 95% CI: 0.35–0.80) in atrial fibrillation patients and a prior history intracranial hemorrhage. Starting oral anticoagulation therapy did not increase the risk of recurrent intracranial hemorrhage (aHR: 1.07, 95% CI: 0.66–1.74), but increased the risk of major bleeding (aHR: 1.38, 95% CI: 1.00–1.91) than no oral anticoagulation therapy. The DOACs had a lower risk of Ischemic Stroke/SE (aHR: 0.84, 95% CI: 0.70–1.00), recurrent intracranial hemorrhage (aHR: 0.63, 95% CI: 0.49–0.82), and all-cause death (aHR: 0.65, 95% CI: 0.48–0.88) compared to warfarin. According to subgroup analyses, starting oral anticoagulation therapy have a higher risk of recurrent intracranial hemorrhage than non-oral anticoagulation therapy (aHR: 1.57, 95% CI: 1.36–1.81) for Asians.Conclusion: After intracranial hemorrhage in atrial fibrillation patients, restarting or initiating oral anticoagulation therapy decreased the risk of Ischemic Stroke/SE and all-cause death but did not increase the risk for recurrent intracranial hemorrhage. Direct oral anticoagulations have better efficacy and safety than warfarin if oral anticoagulation therapy is started. However, starting oral anticoagulation increases the risk for recurrent intracranial hemorrhage in the Asian region.

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“…Lin et al also reported that OACs did not reduce the risk of all-cause mortality (OR 0.85, 95% CI 0.72 to 1.01) in patients with AF and intracranial haemorrhage. 24 One guideline indicates that OAC agents should be discontinued immediately after an intracranial haemorrhage episode. 25 Therefore, OAC therapy after a bleeding event in AKI people is a difficult choice, which requires balancing the risk of rebleeding and the occurrence of thromboembolism.…”

Section: Discussionmentioning

confidence: 99%

Survival benefits of oral anticoagulation therapy in acute kidney injury patients with atrial fibrillation: a retrospective study from the MIMIC-IV database

Wang

2023

BMJ Open

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ObjectiveTo find out the effect of different oral anticoagulation therapies (OAC) on mortality rate in patients with acute kidney injury (AKI) and atrial fibrillation (AF).DesignA retrospective study.SettingThis study was conducted in the Medical Information Mart for Intensive Care IV database.ParticipantsA total of 19 672 patients diagnosed with AKI.Main outcome measuresPatients were categorised into three groups: (1) AF; (2) AKI and AF, OAC−; (3) AKI and AF, OAC+. The primary endpoint was 30-day mortality. Secondary endpoints were the length of stay (LOS) in the intensive care unit (ICU) and hospital. Propensity score matching (PSM) and Cox proportional hazards model adjusted confounding factors. Linear regression was applied to assess the associations between OAC treatment and LOS.ResultsAfter PSM, 2042 pairs of AKI and AF patients were matched between the patients who received OAC and those without anticoagulant treatment. Cox regression analysis showed that, OAC significantly reduce 30-day mortality compared with non-OAC (HR 0.30; 95% CI 0.25 to 0.35; p<0.001). Linear regression analysis revealed that OAC prolong LOS in hospital (11.3 days vs 10.0 days; p=0.013) and ICU (4.9 days vs 4.4 days; p<0.001). OAC did not improve survival in patients with haemorrhage (HR 0.67; 95% CI 0.34 to 1.29; p=0.23). Novel OAC did not reduce mortality in acute-on-chronic renal injury (HR 2.03; 95% CI 1.09 to 3.78; p=0.025) patients compared with warfarin.ConclusionOAC administration was associated with improved short-term survival in AKI patients concomitant with AF.

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Post‐Intracranial Hemorrhage Antithrombotic Therapy in Patients With Atrial Fibrillation

Cited by 11 publications

References 27 publications

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Efficacy and safety of anticoagulation in atrial fibrillation patients with intracranial hemorrhage: A systematic review and meta-analysis

Survival benefits of oral anticoagulation therapy in acute kidney injury patients with atrial fibrillation: a retrospective study from the MIMIC-IV database

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