Type of brain bleed should guide decision to restart warfarin


By Sunalie Silva

6 Mar 2017

A decision to restart antithrombotic therapy in warfarin treated patients who have had an intracranial haemorrhage (ICH) should factor in whether the bleed was spontaneous or trauma-induced, according to Danish researchers.

According to the authors, who conducted an observational study of 2415 warfarin-treated patients with AF who experienced either type of bleed, those who resumed warfarin after spontaneous haemorrhagic stroke had a higher rate of recurrence than patients with traumatic ICH.

Most patients included in the study were aged in their late 70’s and all had experienced an incident ICH event during warfarin treatment.

While patients with a first-time haemorrhagic stroke had a poor prognosis, resumption of warfarin treatment was associated with a lower rate of ischaemic stroke or systemic embolism (SE) a higher rate of recurrent ICH, and significantly lower mortality.

Meanwhile, patients with an incident traumatic ICH had a similarly poor prognosis and lower rate of ischaemic stroke or SE with resumption of warfarin treatment but lower rates of recurrent ICH and mortality after resumption of warfarin treatment.

What’s more, in both groups, warfarin resumption was associated with a lower risk for death within the first year after the event, the authors noted in their paper published in JAMA Internal Medicine.

Writing in a linked editorial journal editor Professor Patrick O’Malley, said that the study, while observational, would help clinicians who deal with the ‘high stakes’ decision of whether or not to put patients with a high thrombotic risk, but who have also had a serious brain bleed, back on their blood thinning medication.

“In the absence of randomised clinical trial data to address complex treatment dilemmas when the therapeutic window of a therapy is narrow, the stakes are high, and the risk for harm is substantial, observational studies can help guide decision making,” he said.

He also added that clinicians could expect to be treating many more patients with ICH in the AF setting as the population ages.

“The risk for major bleeding associated with anticoagulation therapy varies from as low as 0.5% per year in low-morbidity populations to as high as 6% per year among patients with prior major bleeds. Given this incidence and the increasing prevalence of atrial fibrillation with an aging population, we can expect this dilemma to become even more common.”

Calling the mortality difference seen in the study ‘provocative’, he said the finding fills in an evidence gap until a definitive clinical trial can address the unbiased effects of resuming warfarin therapy.

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