Terri V Newman1, Nemin Chen2, Meiqi He3, Samir Saba4, Inmaculada Hernandez3. 1. Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3609 Forbes Ave, Pittsburgh, PA, 15216, USA. tvn6@pitt.edu. 2. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA. 3. Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3609 Forbes Ave, Pittsburgh, PA, 15216, USA. 4. Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Abstract
BACKGROUND: In patients with atrial fibrillation (AF) who survive an anticoagulant-related intracranial hemorrhage (ICH), the benefits of restarting oral anticoagulation (OAC) remain unclear. OBJECTIVE: In this study, we sought to determine the effectiveness and safety associated with resumption of OAC in atrial fibrillation patients who survive an ICH. METHODS: Using 2010-2016 Medicare claims data, we identified patients with non-valvular AF who experienced an OAC-related ICH and survived at least 6 weeks after the ICH (n = 1502). The primary outcomes included the composite of ischemic stroke and transient ischemic attack (TIA), thromboembolism (TE), a composite of ischemic stroke/TIA and TE, recurrent ICH, and all-cause mortality. We constructed Cox proportional hazard models to evaluate the association between post-ICH OAC resumption, which was measured in a time-dependent manner, and the risk of primary outcomes, while controlling for a comprehensive list of covariates. RESULTS: Among patients who survived an ICH, 69% reinitiated OAC within 6 weeks of the event, and among those who resumed OAC, 83% restarted warfarin. There was no significant difference in the risk of ischemic stroke/TIA (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.62-1.21), TE (HR 0.85, 95% CI 0.55-1.32), and ischemic stroke/TIA/TE (HR 0.81, 95% CI 0.61-1.07) between post-ICH OAC use and non-use. Post-ICH OAC use was associated with a lower risk of recurrent ICH (HR 0.62, 95% CI 0.41-0.95) and all-cause mortality (HR 0.48, 95% CI 0.37-0.62) compared with non-OAC use. CONCLUSIONS: In AF patients who survived an ICH, restarting OAC was not associated with a greater risk of recurrent ICH. Evidence from randomized controlled studies is needed to further clarify the clinical benefit of restarting OAC in this high-risk population. Further evaluation of which individuals benefit from restarting OAC is also needed to provide more clinical guidance.
BACKGROUND: In patients with atrial fibrillation (AF) who survive an anticoagulant-related intracranial hemorrhage (ICH), the benefits of restarting oral anticoagulation (OAC) remain unclear. OBJECTIVE: In this study, we sought to determine the effectiveness and safety associated with resumption of OAC in atrial fibrillationpatients who survive an ICH. METHODS: Using 2010-2016 Medicare claims data, we identified patients with non-valvular AF who experienced an OAC-related ICH and survived at least 6 weeks after the ICH (n = 1502). The primary outcomes included the composite of ischemic stroke and transient ischemic attack (TIA), thromboembolism (TE), a composite of ischemic stroke/TIA and TE, recurrent ICH, and all-cause mortality. We constructed Cox proportional hazard models to evaluate the association between post-ICHOAC resumption, which was measured in a time-dependent manner, and the risk of primary outcomes, while controlling for a comprehensive list of covariates. RESULTS: Among patients who survived an ICH, 69% reinitiated OAC within 6 weeks of the event, and among those who resumed OAC, 83% restarted warfarin. There was no significant difference in the risk of ischemic stroke/TIA (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.62-1.21), TE (HR 0.85, 95% CI 0.55-1.32), and ischemic stroke/TIA/TE (HR 0.81, 95% CI 0.61-1.07) between post-ICHOAC use and non-use. Post-ICHOAC use was associated with a lower risk of recurrent ICH (HR 0.62, 95% CI 0.41-0.95) and all-cause mortality (HR 0.48, 95% CI 0.37-0.62) compared with non-OAC use. CONCLUSIONS: In AFpatients who survived an ICH, restarting OAC was not associated with a greater risk of recurrent ICH. Evidence from randomized controlled studies is needed to further clarify the clinical benefit of restarting OAC in this high-risk population. Further evaluation of which individuals benefit from restarting OAC is also needed to provide more clinical guidance.
Authors: Ron Pisters; Deirdre A Lane; Robby Nieuwlaat; Cees B de Vos; Harry J G M Crijns; Gregory Y H Lip Journal: Chest Date: 2010-03-18 Impact factor: 9.410
Authors: Peter Brønnum Nielsen; Torben Bjerregaard Larsen; Flemming Skjøth; Anders Gorst-Rasmussen; Lars Hvilsted Rasmussen; Gregory Y H Lip Journal: Circulation Date: 2015-06-09 Impact factor: 29.690
Authors: J Claude Hemphill; Steven M Greenberg; Craig S Anderson; Kyra Becker; Bernard R Bendok; Mary Cushman; Gordon L Fung; Joshua N Goldstein; R Loch Macdonald; Pamela H Mitchell; Phillip A Scott; Magdy H Selim; Daniel Woo Journal: Stroke Date: 2015-05-28 Impact factor: 7.914
Authors: Graeme J Hankey; Susanna R Stevens; Jonathan P Piccini; Yuliya Lokhnygina; Kenneth W Mahaffey; Jonathan L Halperin; Manesh R Patel; Günter Breithardt; Daniel E Singer; Richard C Becker; Scott D Berkowitz; John F Paolini; Christopher C Nessel; Werner Hacke; Keith A A Fox; Robert M Califf Journal: Stroke Date: 2014-04-17 Impact factor: 7.914
Authors: Zien Zhou; Jie Yu; Cheryl Carcel; Candice Delcourt; Jiehui Shan; Richard I Lindley; Bruce Neal; Craig S Anderson; Maree L Hackett Journal: BMJ Open Date: 2018-05-14 Impact factor: 2.692
Authors: Terri Victoria Newman; Nico Gabriel; Qinfeng Liang; Coleman Drake; Samar R El Khoudary; Chester B Good; Walid F Gellad; Inmaculada Hernandez Journal: J Manag Care Spec Pharm Date: 2022-02