Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a retained consultant for Procter & Gamble and Pfizer.
SOURCE: Tsivgoulis G, Wilson D, Katsanos AH, et al. Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage. Ann Neurol 2018; Sep. 26. doi:10.1002/ana.2542. [Epub ahead of print].
Intracerebral hemorrhage (ICH) is the most dangerous and feared complication of oral anticoagulation and leads to a high mortality. Although the incidence is declining because of improved treatment of hypertension, the overall number of cases is rising because of more widespread use of antithrombotic medications to respond to the increasing prevalence of atrial fibrillation. In recent years, clinicians have started treating patients more often with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) as opposed to vitamin K antagonists (VKA-ICH), such as warfarin, and debate has continued about the relative risk of hemorrhage with these two classes of oral anticoagulants.
Tsivgoulis et al performed a systematic review to evaluate the relative risk of hemorrhage associated with these two classes of medications. They looked at individual patient data in cohort studies that compared clinical and radiographic outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. They assessed all outcomes in multivariate regression analyses that were adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. They examined seven eligible studies, which comprised 219 patients with a NOAC-ICH and 831 patients with VKA-ICH (mean age, 77 years; 52.5% females). The 30-day mortality was similar between both groups (24.3% vs. 26.5%; hazard ratio, 0.94). However, in multivariate analyses adjusted for cofounders, NOAC-ICH was associated with a lower NIH stroke scale score on admission, a lower likelihood of a severe stroke on admission, and a smaller baseline hematoma volume. The two groups did not differ in the likelihood of small hematoma less than 30 cm³, the risk of hematoma expansion, in-hospital mortality, functional status at discharge, or functional status at three months.
The authors concluded that although functional outcome at discharge, one month, or three months was comparable between the two groups, patients treated with a NOAC had smaller baseline hematoma volumes and less severe acute stroke syndromes on admission to the hospital.