Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage

Abstract

Background and Purpose: Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH). Methods: We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHA 2 DS 2 -VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer. Results: We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11–1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years. Conclusions: Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.

The efficacy and risk factors of mechanical thrombectomy for the treatment of vertebrobasilar artery occlusion: a single center study

“…Despite its relatively low incidence, acute VBAO is the most dangerous type of cerebral vessel occlusion and can be caused by severe local atherosclerotic stenosis or distant embolization (4), with the former being more common (5). Without any specific treatment, the mortality rate of patients with acute ischemic stroke caused by VBAO is approximately 80-90% (6). Therefore, effective treatments for VBAO have attracted much attention globally.…”

Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both?

“…AF is associated with an increased risk of intracranial hemorrhage, although this is largely related to concomitant anticoagulant therapy. In a limited number of cases, it has been shown that patients with atrial fibrillation can develop extracranial hemorrhage (ECH) [99]. However, it is unclear whether patients with AF may have a better or worse prognosis than those without arrhythmia [100].…”

“…The bleeding risk is known as the main problem of all anticoagulant therapies, despite their proven effectiveness [99]. The introduction of direct oral anticoagulants (DOACs) into clinical practice means that major hemorrhages, especially intracranial, associated with therapy are certainly reduced; however, the risk of bleeding, even with these drugs, is not eliminated.…”

“…The introduction of direct oral anticoagulants (DOACs) into clinical practice means that major hemorrhages, especially intracranial, associated with therapy are certainly reduced; however, the risk of bleeding, even with these drugs, is not eliminated. Hence, there is a need to develop new drugs that are ideally capable of overcoming the current limitations of therapies in use (Figure 4) [99]. In particular, it would seem that the risk increases in conjunction with acute renal failure as all direct and indirect anticoagulant drugs have a predominantly renal excretion mechanism and are therefore subject to hyperaccumulation with the possibility of an increase in major and minor hemorrhages [126].…”

Diagnosis and Management of Cardioembolic Stroke

“…In patients with a history of extracranial hemorrhage, studies have shown an increased risk of ischemic stroke. Thus, in these patients, anticoagulation should generally be resumed after the bleeding source is successfully treated 34 . On the other hand, left atrial appendage occlusion can be considered in patients with recurrent major extracranial hemorrhage or those whose bleeding source cannot be successfully treated such as those with multiple gastrointestinal arteriovenous malformations.…”