Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Abstract

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures

“…This score was effective in identifying patients with an increased risk of ICH. Specifically, previous neurosurgery, post-traumatic amnesia, post-traumatic vomiting, post-traumatic loss of consciousness, and trauma above the clavicles were variables associated with an increased odds ratio of ICH [46].…”

“…Although specific studies to assess the management of anticoagulated patients with ICH are unavailable, the Swiss Society of Hematology has recently provided some recommendations [44,46,47]. Specifically, in the presence of ICH, andexanet alfa has been suggested in those patients without severe neurological impairment (Glasgow Coma Scale >7), with symptom onset occurring in less than sixh, life expectancy >1 month, and last intake of apixaban/rivaroxaban <15 h or anti-Xa >100 ng/mL.…”

Exploring the Perioperative Use of DOACs, off the Beaten Track

“…Indeed, taking into account exclusively modifiable bleeding risk factors was an ineffective approach [ 36 , 37 , 38 ]. On the contrary, a more complete evaluation based on a standardized score system, including modifiable and non-modifiable factors, has been recommended (Class I level B) [ 7 , 13 , 29 , 39 , 40 , 41 ].…”

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

“…The elderly represent approximately 31–43% of the population in phase 3 DOAC trials, which shows that safety and efficacy were not affected by age [ 141 ]. The use of DOACs reduces the risk of IH more than VKAs [ 142 ] and, regarding extracranial bleeding, there is a significant interaction with age but only for dabigatran [ 143 ], which could be reduced by avoiding concurrent APT and using proton-pump inhibitors. Age can also be a direct or indirect (due to weight or kidney impairment) criterion for dose reduction, but it does not change the overall effect of DOACs.…”