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In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation

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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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Authors and Affiliations

  1. Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA

    Teng J. Peng, Catherine Viscoli & Kevin N. Sheth

  2. Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA

    Pooja Khatri

  3. Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Stacey Q. Wolfe

  4. Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA

    Nirav R. Bhatt

  5. Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA

    Tarun Girotra

  6. Department of Neurology, Weill Cornell Medical College, New York, NY, USA

    Hooman Kamel

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  1. Teng J. Peng
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  2. Catherine Viscoli
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  8. Kevin N. Sheth
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Correspondence to Kevin N. Sheth.

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No external funding was used in the preparation of this article.

Conflict of interest

Dr. Peng, Dr. Viscoli, Dr. Wolfe, Dr. Bhatt, and Dr. Girotra have no relevant financial or nonfinancial interests to disclose. Dr. Khatri receives funding from Bayer for her effort as national leader of the PACIFIC-Stroke trial. Dr. Kamel serves as a primary investigator for the NIH-funded ARCADIA trial (NINDS U01NS095869), which receives in-kind study drug from the BMS-Pfizer Alliance for Eliquis® and ancillary study support from Roche Diagnostics; as Deputy Editor for JAMA Neurology; on clinical trial steering/executive committees for Medtronic, Janssen, and Javelin Medical; and on endpoint adjudication committees for NovoNordisk and Boehringer-Ingelheim. Dr. Sheth receives grant support from R01NS110721-01A1, U01NS106513, U24NS107215, U24NS107136, RO1NR018335, Bugher Center of Excellence in Hemorrhagic Stroke Research, American Heart Association/American Stroke Association, 2020AHA000BFCHS00199732, Biogen, Bard, and Hyperfine.

Authors' contributions

TJP, CV, and KNS designed and conceptualized the study, performed the literature search, screened available data, and drafted the manuscript. SQW, PK, NRB, TG, and HK co-authored, edited, and critically reviewed the manuscript. All authors have read and approved the final manuscript for submission.

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Peng, T.J., Viscoli, C., Khatri, P. et al. In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation. Drugs 82, 965–977 (2022). https://doi.org/10.1007/s40265-022-01729-9

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