Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study

Abstract

Background: In patients with intracerebral hemorrhage (ICH) and prevalent atrial fibrillation (AF), the optimal stroke prevention strategy is unclear. We sought to estimate the risk of cerebrovascular events among ICH survivors with AF. Methods: We used the Danish Stroke Registry to identify patients with incident ICH and prevalent AF between 2003 and 2018. Key inclusion/exclusion criteria of the PRESTIGE-AF (Prevention of Stroke in Intracerebral hemorrhage Survivors With Atrial Fibrillation) trial were applied. Cumulative incidence of recurrent ICH, cerebrovascular ischemic event, and all-cause death were investigated after one year. Results: A total of 1885 patients (median age 80.0 years; 47.6% females) were included in the study. We observed 191 cerebrovascular events and 650 all-cause deaths, and more cerebrovascular ischemic events (N=63) than recurrent ICH events (N=40). Risks of recurrent ICH, cerebrovascular ischemic event, and all-cause death were 1.5%, 3.2%, and 30.3%, respectively, among patients not exposed to OAC during follow-up. The cumulative incidences were 2.8% for recurrent ICH, 3.2% for cerebrovascular ischemic events, and 22.0% for all-cause death among patients initiating/resuming OAC during follow-up. Conclusions: We observed a high risk of cerebrovascular ischemic events and a very high risk of all-cause death at one year after the incident ICH. The results of ongoing clinical trials are warranted to determine optimal stroke prevention treatment among ICH survivors with concomitant AF.

Long-Term Risk of Arterial Thrombosis After Intracerebral Hemorrhage: MUCH-Italy

“…Some of them were clearly underpowered for multivariable analysis because of the rather modest number of patients involved and the short length of follow-up 2 ; others lacked data on antithrombotic therapy or location of the cerebral hematoma, 20 captured end points that were a composite of thrombotic and hemorrhagic events making it hard to derive precise information on arterial thrombosis; and a few had limited generalizability because of the highly selected cohorts under investigation. 2 , 20 , 21 Recently, a pooled analysis of 4 US population-based studies with ≈50 000 participants provided novel findings implicating ICH as a potential risk marker for subsequent arterial ischemic events. 22 Notwithstanding, as admitted by the authors themselves, the study could not explore the association between hematoma location and the risk of subsequent arterial thrombosis because of the lack of data or allow to perform subgroup analyses of recurrent ICH owing to the low number of such events.…”

Hospitalization rates, stroke unit care, and recurrence rates in Austria’s stroke cohort Epidemiologic analysis of 102,107 patients in a nation-wide acute stroke cohort between 2015 and 2019

“…Also, all-cause death within 1 year was lower in patients with ICH and atrial fibrillation resuming/initiating oral anticoagulation (22%) compared to patients where oral anticoagulation was not recommenced (30.3%). 21 Another possible reason might be a better compliance and blood pressure target achievement through early use of combination pills in arterial hypertension 22 instead of initiating antihypertensive medication using monotherapy and consecutive dose escalation.…”

Management and Prognosis of Acute Stroke in Atrial Fibrillation

“…The risk of IS often exceeds the risk of re-ICH in AF patients, with risk-benefit analyses favoring resumption of OAC therapy after bleeding has resolved [138]. Resumption of OAC has been associated with a lower risk of thromboembolic events, lower rates of mortality, and no increase in re-ICH risk in meta-analyses of OAC-related ICH [139][140][141].…”