It has always been a therapeutic dilemma whether to anticoagulate patients with Afib and a history of prior intracranial hemorrhage (ICH). This study used a Taiwanese national database to identify 12,917 patients with an ICH history and new AF and to analyze outcomes according to whether they received no treatment, antiplatelet therapy, or warfarin.
During a follow-up of 3.3 years, there were 1599 ICH events and 1675 ischemic-stroke events. A history of ICH was an independent risk factor for further ICH (HR = 5.27). Diabetes and vascular disease and antiplatelet therapy were also risk factors for recurrent ICH. Of the 8211 (64%) patients with an ICH history and no antithrombotic treatment, the annual risk for ischemic stroke was 5.8%. Compared with no antithrombotic therapy, antiplatelet therapy did not lower the risk for ischemic stroke. Warfarin was associated with a lower risk for ischemic stroke but a higher risk for ICH, compared with not receiving antithrombotic therapy. In an analysis of patients based on CHA2DS2-VASc, the risk-benefit ratio for ischemic stroke or ICH favored receiving warfarin rather than no treatment in patients with a CHADS2-VASc score of 6 or more.
Therefore, based on this retrospective review, patients with AF and prior ICH should undergo warfarin anticoagulation if they have valvular AF or non-valvular AF and a CHADS2-VASc score of 6 or more. On the other hand, patients with AF, diabetes and vascular disease but have a CHADS2-VASc score of 5 or less should probably have no antithrombotic therapy due to a high risk of recurrent ICH. A prospective RCT is definitely needed to help guide therapy.
Chao T-F et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation 2016 Apr 19; 133:1540.