OAC After Brain Bleed in AF Tied to Lower Stroke Risk

TOPLINEAmong patients with atrial fibrillation (AF) and previous intracranial bleeding, oral anticoagulation (OAC) was associated with reduced risks for ischemic stroke (IS) and death compared with no anticoagulation, a study showed. Direct oral anticoagulant (DOAC) users had lower risks for IS and death, with no significant difference in the risk for intracranial bleeding, whereas warfarin users had an increased risk for recurrent intracranial bleeding.METHODOLOGYA nationwide Finnish cohort study included data from 1502 adults with a diagnosis of first-ever AF (median age, 78 years; 44% women) between 2010 and 2017 who had intracranial bleeding at least 120 days before AF diagnosis and a CHA2DS2-VA score ≥ 2.Patients were categorized by anticoagulation strategy at 90 days after AF diagnosis: 15% received DOACs, 29% warfarin, and 56% no OAC. Follow-up continued for up to 2 years.Researchers estimated absolute risks for recurrent intracranial bleeding, IS, and death from other causes.In the cohort, 41% had only traumatic intracranial bleeding in their history, while 59% had nontraumatic intracranial bleeding.Warfarin users were further stratified by time in therapeutic range (TTR; n = 374), with 48.12% achieving a TTR of 70% or more.TAKEAWAYAt 2 years, the adjusted absolute risks for IS were 1.9% for DOAC users, 3.1% for warfarin users, and 6.1% for those not on OAC. Corresponding risks for intracranial bleeding were 2.7%, 6.5%, and 2.9%, respectively, and those for death from other causes were 10.1%, 15.6%, and 24.6%, respectively.Compared with those not on OAC, DOAC users had lower risks for IS (hazard ratio [HR], 0.17; 95% CI, 0.04-0.71) and death (HR, 0.20; 95% CI, 0.09-0.46); however, they showed no significant difference in the risk for intracranial bleeding (HR, 0.70; 95% CI, 0.19-2.50).Warfarin use was linked to lower risks for IS (HR, 0.49; 95% CI, 0.26-0.93) and death (HR, 0.60; 95% CI, 0.44-0.80), but a higher risk for intracranial bleeding (HR, 1.85; 95% CI, 1.01-3.41).Among patients on warfarin, a TTR of 70% or more was linked to significantly lower risks for IS (HR, 0.24; 95% CI, 0.08-0.79) and death (HR, 0.19; 95% CI, 0.10-0.36); these benefits were attenuated when the TTR was less than 70% or missing.IN PRACTICE"Our findings may help clinicians make more individualized treatment decisions when trying to prevent stroke in people with AFib and prior brain bleeds. However, more research is needed to identify who is most likely to benefit and who may still face a higher bleeding risk," study investigator Paula Tiili, Helsinki University Hospital, Finland, said in a press release.SOURCEThe study was published online on October 21 in Neurology.LIMITATIONSThe study was limited by residual confounding, potential selection bias, potential outcome misclassification, and the lack of data on hemorrhage severity, hematoma volume, anatomical location, imaging characteristics, and etiology. The small number of events, particularly among DOAC users, limited the power for subgroup analyses. The findings may not have been applicable to the acute phase after a bleed or AF diagnosis.DISCLOSURESThe study received no specific funding. Disclosure information for the study investigators is available in the original study publication.This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.