Fatal intracranial haemorrhage occurring after oral anticoagulant treatment initiation for secondary stroke prevention in patients with atrial fibrillation

Abstract

Background and Purpose In this pooled analysis of 7 multicenter cohorts we investigated potential differences in the incidence, characteristics and outcomes between intracranial hemorrhages (ICHs) associated with the use of non‐vitamin K oral anticoagulants (NOAC‐ICH) or vitamin K antagonists (VKA‐ICH) in ischemic stroke (IS) patients after oral anticoagulant treatment initiation for atrial fibrillation (AF). Methods We included data from 4.912 eligible AF patients who were admitted in a stroke unit with IS or transient ischemic attack (TIA) and who were treated with either VKAs or NOACs within 3 months post‐stroke. Fatal ICH was defined as death occurring during the first 30‐days after ICH onset. We additionally performed a meta‐analysis of available observational studies reporting 30‐day mortality rates from NOAC‐ICH or VKA‐ICH onset. Results During 5970 patient‐years of follow‐up 71 participants had an ICH, of whom 20 were NOAC‐ICH and 51 VKA‐ICH. Patients in the two groups had comparable baseline characteristics, except for the higher prevalence of kidney disease in VKA‐ICH patients. There was a non‐significant higher number of fatal ICH in patients with VKA (11 events per 3,385 patient‐years) than in those with NOAC (3 events per 2,623 patient‐years; HR=0.32,95%CI:0.09‐1.14). Three‐month functional outcomes were similar (p>0.2) in the two groups. The meta‐analysis showed a lower 30‐day mortality risk for patients with NOAC‐ICH compared to VKA‐ICH (RR=0.70,95%CI:0.51‐0.95). Conclusions NOAC‐ICH and VKA‐ICH occurring during secondary stroke prevention of AF patients have comparable baseline characteristics and outcomes, except for the risk of fatal ICH within 30 days, which might be greater in VKA‐ICH.