Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy

Rivera‐Caravaca, José Miguel; Esteve‐Pastor, María Asunción; Camelo-Castillo, Anny; Ramírez-Macías, Inmaculada; Lip, Gregory Y.H.; Roldán, Vanessa; Marı́n, Francisco

doi:10.1080/14656566.2020.1789099

Cited by 6 publications

(3 citation statements)

References 172 publications

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“…For AF patients who survived ICH, whether to prescribe OACs is a dilemma that clinicians usually face, as it is difficult to balance between the risk of thromboembolism and a recurrent hemorrhage. Anticoagulation therapy for AF patients surviving ICH was still a controversial issue and decisions are mainly based on observational studies and expert consensus (2,5,6,22). Therefore, we performed this most comprehensive meta-analysis, the first of this kind to include two most recently published RCTs (11,12), investigating the optimal therapeutic strategy and comparing the effectiveness and safety of starting OAC therapy and avoiding OAC in AF patients with a history of ICH during long-term follow-up.…”

Section: Discussionmentioning

confidence: 99%

“…This leads to a therapeutic dilemma as to whether starting or permanently avoiding anticoagulation is the best long-term strategy for AF patients after ICH. Clinicians have to weigh the risk of thromboembolism against the risk of recurrent ICH (5,6). Individual studies have attempted to address this challenge but have not yet been able to provide clear guidance on this issue because of conflicting results.…”

Section: Introductionmentioning

confidence: 99%

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Effect of oral anticoagulation therapy in atrial fibrillation patients with a history of intracranial hemorrhage: a systematic review and meta-analysis

Liu¹,

Hou²,

Liu³

et al. 2022

Ann Palliat Med

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Background: Use of oral anticoagulants (OACs) among atrial fibrillation (AF) patients surviving intracranial hemorrhage (ICH) represents a challenge due to the difficult balance between thrombosis and hemorrhage.Methods: We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of OACs resumption in AF patients with a history of ICH during long-term follow-up. The outcome measures were ischemic stroke (IS), IS or systemic embolism (SE), all-cause death, recurrent ICH and major bleeding.Meta-analyses of pooled odds ratios (ORs) were conducted with random-effects models.Results: A total of 2 randomized controlled trials (RCTs) and 9 observational studies were included, covering 18,115 patients with AF and a history of ICH. The risk of IS was not statistically different between the group of patients receiving OAC therapy and the no-OAC group (OR: 0.41, 95% CI: 0.16 to 1.0, P=0.05). The rate of IS or SE (OR: 0.42, 95% CI: 0.27 to 0.70, P=0.0008), all-cause death (OR: 0.54, 95% CI: 0.41 to 0.70, I 2 =42%, P<0.00001) were significantly decreased in patients receiving OAC therapy compared to those with no-OAC therapy. The pooled OR estimates for ICH recurrence (OR: 1.46, 95% CI: 0.94 to 2.26, P=0.09) and major bleeding (OR: 1.35, 95% CI: 0.86 to 2.11, P=0.19) were not significantly increased in the OAC therapy group. There was heterogeneity between the results of observational studies and RCTs in terms of all-cause death (I 2 =83.4%).Discussion: Considering the heterogeneity in results between observational studies and RCTs, as well as the limited number and small size of RCTs, high grade evidences are needed. Pooled analysis is required when more RCTs are completed in the future to resolve this therapeutic dilemma.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Effect of oral anticoagulation therapy in atrial fibrillation patients with a history of intracranial hemorrhage: a systematic review and meta-analysis

Liu¹,

Hou²,

Liu³

et al. 2022

Ann Palliat Med

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show abstract

“…Third, the lack of a reversal agent. A combination of factors, including market forces led to the development of reversal agents [ 25 ] and management guidelines [ 26 ] for patients with and those at risk for DOAC-associated bleeding complications. There are opportunities for improvement and further development of reversal agents [ 27 ].…”

Section: The Importance Of Drug Reversibilitymentioning

confidence: 99%

Factor Xa inhibitors: critical considerations for clinical development and testing

Becker

2021

J Thromb Thrombolysis

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The selection of factor (F) X and its activated protease FXa for targeted inhibition to prevent and treat thrombotic conditions is based on an understanding of coagulation biochemistry, sequential steps that occur on tissue factor bearing cells and the interface of coagulation proteins, platelets, mononuclear cells and the nuclear constituents of inflammatory cells. The goal for developing direct oral FXa inhibitors was to achieve rapid, selective, predictable, safe and effective anticoagulation across a broad group of patients expected to derive benefit. The history and development in patient care are exemplars of knowledge, translation and collaboration between the public and private sectors.

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Risk of intracranial hemorrhage with direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials

Wang

et al. 2021

J Neurol

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Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy

Cited by 6 publications

References 172 publications

Effect of oral anticoagulation therapy in atrial fibrillation patients with a history of intracranial hemorrhage: a systematic review and meta-analysis

Effect of oral anticoagulation therapy in atrial fibrillation patients with a history of intracranial hemorrhage: a systematic review and meta-analysis

Factor Xa inhibitors: critical considerations for clinical development and testing

Risk of intracranial hemorrhage with direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials

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