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Abstract
Objective: To perform a systematic review and meta-analysis of studies reporting recurrent intracranial hemorrhage (ICH) and ischemic stroke (IS) in ICH survivors with atrial fibrillation (AF) during long-term follow-up.
Methods: A comprehensive literature search including MEDLINE, EMBASE, Cochrane library, clinical trials registry was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We considered studies capturing outcome events (ICH recurrence and IS) for ≥3 months and treatment exposure to vitamin K antagonists (VKAs), antiplatelet agents (APAs), or no antithrombotic medication (no-ATM). Corresponding authors provided aggregate data for IS and ICH recurrence rate between 6 weeks after the event and 1 year of follow-up for each treatment exposure. Meta-analyses of pooled rate ratios (RRs) were conducted with the inverse variance method.
Results: Seventeen articles met inclusion criteria. Seven observational studies enrolling 2,452 patients were included in the meta-analysis. Pooled RR estimates for IS were lower for VKAs compared to APAs (RR = 0.45, 95% confidence interval [CI] 0.27–0.74, p = 0.002) and no-ATM (RR = 0.47, 95% CI 0.29–0.77, p = 0.002). Pooled RR estimates for ICH recurrence were not significantly increased across treatment groups (VKA vs APA: RR = 1.34, 95% CI 0.79–2.30, p = 0.28; VKA vs no-ATM: RR = 0.93, 95% CI 0.45–1.90, p = 0.84).
Conclusions: In observational studies, anticoagulation with VKA is associated with a lower rate of IS than APA or no-ATM without increasing ICH recurrence significantly. A randomized controlled trial is needed to determine the net clinical benefit of anticoagulation in ICH survivors with AF.
GLOSSARY
- AF=
- atrial fibrillation;
- APA=
- antiplatelet agent;
- APACHE-AF=
- Apixaban Versus Antiplatelet Drugs or no Antithrombotic Drugs After Anticoagulation-Associated Intracerebral Haemorrhage in Patients With Atrial Fibrillation;
- ATM=
- antithrombotic medication;
- AVERROES=
- A Phase III Study of Apixaban in Patients With Atrial Fibrillation;
- CI=
- confidence interval;
- DOAC=
- direct oral anticoagulant;
- ICD-10=
- International Classification of Diseases, 10th revision;
- ICH=
- intracranial hemorrhage;
- IS=
- ischemic stroke;
- OAC=
- oral anticoagulant;
- PRISMA=
- Preferred Reporting Items for Systematic Reviews and Meta-Analyses;
- RR=
- rate ratio;
- VKA=
- vitamin K antagonist
Footnotes
↵* These authors contributed equally to this work.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at Neurology.org
- Received December 29, 2016.
- Accepted in final form May 23, 2017.
- © 2017 American Academy of Neurology
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