Antithrombotics and Subdural Risk
SOURCE: Gaist D, Garcia Rodriguez LA, Hellfritzsch, et al. Association of antithrombotic drug use with subdural hematoma risk. JAMA 2017;317:836-846.
Before you digest the somewhat concerning observations of the Danish case-control data discussed below, it is important to remember that the risk of intracerebral hemorrhage in patients taking long-term anticoagulation (most commonly for atrial fibrillation) is < 0.5% per year, and for atrial fibrillation patients appropriately stratified by CHA2DS2-VASC, consistently outweighed by the beneficial risk reduction of thrombotic episodes.
That said, Gaist et al reported on a database of patients in Denmark (n = 10,100) with first subdural hematoma (SDH) compared to controls (n = 484,386). Included in the authors’ definition of antithrombotics were warfarin, aspirin, clopidogrel, the dipyridamole/aspirin combination capsule, and direct anticoagulants (dabigatran, apixaban, and rivaroxaban). Perhaps not surprisingly, almost half the subjects who incurred a SDH were receiving some antithrombotic medication, either alone or in combination.
Overall, the risk for SDH was greatest when antithrombotic medications were combined, especially with warfarin/antiplatelet combinations (odds ratios, 4.0-7.9). The only exception to this range of increased risk with combinations was about the dipyridamole/aspirin combination treatment (that is, dipyridamole/aspirin alone), for which the odds ratio for SDH risk was not statistically significantly increased. Intracranial bleeding is more frequent in patients who take antithrombotic treatments. However, for appropriately selected users, the benefits of thrombosis risk reduction generally outweigh bleeding risks.
In a recent study, the risk for subdural hematoma was greatest when antithrombotic medications were combined, especially with warfarin/antiplatelet combinations.
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