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Forfang E, Larsen KT, Salman RA, Bell SM, Wester P, Berge E, Wyller TB, Rønning OM. Antithrombotic treatment after intracerebral hemorrhage: Surveys among stroke physicians in Scandinavia and the United Kingdom. Health Sci Rep 2023; 6:e1059. [PMID: 36698713 PMCID: PMC9854165 DOI: 10.1002/hsr2.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
Background and Aims It is unclear whether patients with previous intracerebral hemorrhage (ICH) should receive antithrombotic treatment to prevent ischemic events. We assessed stroke physicians' opinions about this, and their views on randomizing patients in trials assessing this question. Methods We conducted three web-based surveys among stroke physicians in Scandinavia and the United Kingdom. Results Eighty-nine of 205 stroke physicians (43%) responded to the Scandinavian survey, 161 of 180 (89%) to the UK antiplatelet survey, and 153 of 289 (53%) to the UK anticoagulant survey. In Scandinavia, 19 (21%) stroke physicians were uncertain about antiplatelet treatment after ICH for ischemic stroke or transient ischemic attack (TIA) and 21 (24%) for prior myocardial infarction. In the United Kingdom, 116 (77%) were uncertain for ischemic stroke or TIA and 115 (717%) for ischemic heart disease. In Scandinavia, 32 (36%) were uncertain about anticoagulant treatment after ICH for atrial fibrillation, and 26 (29%) for recurrent deep vein thrombosis or pulmonary embolism. In the United Kingdom, 145 (95%) were uncertain about anticoagulants after ICH in at least some cases. In both regions combined, 191 of 250 (76%) would consider randomizing ICH survivors in a trial of starting versus avoiding antiplatelets, and 176 of 242 (73%) in a trial of starting versus avoiding anticoagulants. Conclusion Considerable proportions of stroke physicians in Scandinavia and the United Kingdom were uncertain about antithrombotic treatment after ICH. A clear majority would consider randomizing patients in trials assessing this question. These findings support the need for such trials.
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Affiliation(s)
- Elisabeth Forfang
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Kristin Tveitan Larsen
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | | | - Simon M. Bell
- Sheffield Institute for Translational NeuroscienceUniversity of SheffieldSheffieldUK
| | - Per Wester
- Department of Public Health and Clinical ScienceUniversity of UmeåUmeåSweden
- Department of Clinical ScienceKarolinska Institutet Danderyds HospitalStockholmSweden
| | - Eivind Berge
- Department of CardiologyOslo University HospitalOsloNorway
| | - Torgeir Bruun Wyller
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Ole Morten Rønning
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of NeurologyAkershus University HospitalNordbyhagenNorway
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Peng TJ, Viscoli C, Khatri P, Wolfe SQ, Bhatt NR, Girotra T, Kamel H, Sheth KN. In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation. Drugs 2022; 82:965-977. [PMID: 35657478 DOI: 10.1007/s40265-022-01729-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/03/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA
| | - Catherine Viscoli
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nirav R Bhatt
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Tarun Girotra
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA.
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Nielsen PB, Melgaard L, Overvad TF, Jensen M, Larsen TB, Lip GYH. Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study. Stroke 2022; 53:2559-2568. [PMID: 35414198 PMCID: PMC9311292 DOI: 10.1161/strokeaha.121.038331] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: In patients with intracerebral hemorrhage (ICH) and prevalent atrial fibrillation (AF), the optimal stroke prevention strategy is unclear. We sought to estimate the risk of cerebrovascular events among ICH survivors with AF. Methods: We used the Danish Stroke Registry to identify patients with incident ICH and prevalent AF between 2003 and 2018. Key inclusion/exclusion criteria of the PRESTIGE-AF (Prevention of Stroke in Intracerebral hemorrhage Survivors With Atrial Fibrillation) trial were applied. Cumulative incidence of recurrent ICH, cerebrovascular ischemic event, and all-cause death were investigated after one year. Results: A total of 1885 patients (median age 80.0 years; 47.6% females) were included in the study. We observed 191 cerebrovascular events and 650 all-cause deaths, and more cerebrovascular ischemic events (N=63) than recurrent ICH events (N=40). Risks of recurrent ICH, cerebrovascular ischemic event, and all-cause death were 1.5%, 3.2%, and 30.3%, respectively, among patients not exposed to OAC during follow-up. The cumulative incidences were 2.8% for recurrent ICH, 3.2% for cerebrovascular ischemic events, and 22.0% for all-cause death among patients initiating/resuming OAC during follow-up. Conclusions: We observed a high risk of cerebrovascular ischemic events and a very high risk of all-cause death at one year after the incident ICH. The results of ongoing clinical trials are warranted to determine optimal stroke prevention treatment among ICH survivors with concomitant AF.
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Affiliation(s)
- Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Denmark. (P.B.N., L.M., M.J. T.B.L.).,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., L.M., T.B.L, G.Y.H.L.)
| | - Line Melgaard
- Department of Cardiology, Aalborg University Hospital, Denmark. (P.B.N., L.M., M.J. T.B.L.).,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., L.M., T.B.L, G.Y.H.L.)
| | | | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Denmark. (P.B.N., L.M., M.J. T.B.L.)
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark. (P.B.N., L.M., M.J. T.B.L.).,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., L.M., T.B.L, G.Y.H.L.)
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., L.M., T.B.L, G.Y.H.L.).,Liverpool Centre for Cardiovascular Sciences, University Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.)
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Schreuder FHBM, van Nieuwenhuizen KM, Hofmeijer J, Vermeer SE, Kerkhoff H, Zock E, Luijckx GJ, Messchendorp GP, van Tuijl J, Bienfait HP, Booij SJ, van den Wijngaard IR, Remmers MJM, Schreuder AHCML, Dippel DW, Staals J, Brouwers PJAM, Wermer MJH, Coutinho JM, Kwa VIH, van Gelder IC, Schutgens REG, Zweedijk B, Algra A, van Dalen JW, Jaap Kappelle L, Rinkel GJE, van der Worp HB, Klijn CJM. Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial. Lancet Neurol 2021; 20:907-916. [PMID: 34687635 DOI: 10.1016/s1474-4422(21)00298-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with atrial fibrillation who survive an anticoagulation-associated intracerebral haemorrhage, a decision must be made as to whether restarting or permanently avoiding anticoagulation is the best long-term strategy to prevent recurrent stroke and other vascular events. In APACHE-AF, we aimed to estimate the rates of non-fatal stroke or vascular death in such patients when treated with apixaban compared with when anticoagulation was avoided, to inform the design of a larger trial. METHODS APACHE-AF was a prospective, randomised, open-label, phase 2 trial with masked endpoint assessment, done at 16 hospitals in the Netherlands. Patients who survived intracerebral haemorrhage while treated with anticoagulation for atrial fibrillation were eligible for inclusion 7-90 days after the haemorrhage. Participants also had a CHA2DS2-VASc score of at least 2 and a score on the modified Rankin scale (mRS) of 4 or less. Participants were randomly assigned (1:1) to receive oral apixaban (5 mg twice daily or a reduced dose of 2·5 mg twice daily) or to avoid anticoagulation (oral antiplatelet agents could be prescribed at the discretion of the treating physician) by a central computerised randomisation system, stratified by the intention to start or withhold antiplatelet therapy in participants randomised to avoiding anticoagulation, and minimised for age and intracerebral haemorrhage location. The primary outcome was a composite of non-fatal stroke or vascular death, whichever came first, during a minimum follow-up of 6 months, analysed using Cox proportional hazards modelling in the intention-to-treat population. APACHE-AF is registered with ClinicalTrials.gov (NCT02565693) and the Netherlands Trial Register (NL4395), and the trial is closed to enrolment at all participating sites. FINDINGS Between Jan 15, 2015, and July 6, 2020, we recruited 101 patients (median age 78 years [IQR 73-83]; 55 [54%] were men and 46 [46%] were women; 100 [99%] were White and one [1%] was Black) a median of 46 days (IQR 21-74) after intracerebral haemorrhage. 50 were assigned to apixaban and 51 to avoid anticoagulation (of whom 26 [51%] started antiplatelet therapy). None were lost to follow-up. Over a median follow-up of 1·9 years (IQR 1·0-3·1; 222 person-years), non-fatal stroke or vascular death occurred in 13 (26%) participants allocated to apixaban (annual event rate 12·6% [95% CI 6·7-21·5]) and in 12 (24%) allocated to avoid anticoagulation (11·9% [95% CI 6·2-20·8]; adjusted hazard ratio 1·05 [95% CI 0·48-2·31]; p=0·90). Serious adverse events that were not outcome events occurred in 29 (58%) of 50 participants assigned to apixaban and 29 (57%) of 51 assigned to avoid anticoagulation. INTERPRETATION Patients with atrial fibrillation who had an intracerebral haemorrhage while taking anticoagulants have a high subsequent annual risk of non-fatal stroke or vascular death, whether allocated to apixaban or to avoid anticoagulation. Our data underline the need for randomised controlled trials large enough to allow identification of subgroups in whom restarting anticoagulation might be either beneficial or hazardous. FUNDING Dutch Heart Foundation (grant 2012T077).
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Affiliation(s)
- Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Gert-Jan Luijckx
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Gert P Messchendorp
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Julia van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - H Paul Bienfait
- Department of Neurology, Gelre Hospital, Apeldoorn, Netherlands
| | - Suzanne J Booij
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Haaglanden MC, The Hague, Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Diederik W Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Isabelle C van Gelder
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Berber Zweedijk
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan Willem van Dalen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands.
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