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Systematic review
Anticoagulant in atrial fibrillation patients with prior intracranial haemorrhage: a meta-analysis
  1. Huiya Cai1,2,
  2. Guoquan Chen3,
  3. Wei Hu2,
  4. Chunjiao Jiang1
  1. 1 Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
  2. 2 Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
  3. 3 Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
  1. Correspondence to Dr Wei Hu, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China; 2516125{at}zju.edu.cn

Abstract

Background The benefit of resuming anticoagulation in atrial fibrillation (AF) patients with prior intracranial haemorrhage (ICH) and which anticoagulant to choose are controversial.

Summary of review PubMed, Embase, Web of Science and the Cochrane Library were searched from their inception until 13 February 2022. Thirteen eligible articles (17 600 participants) were collected, including 11 real-world studies (n=17 296) and 2 randomised controlled trials (RCTs) (n=304). Compared with no anticoagulants, oral anticoagulation (OAC) was not associated with an increased risk of ICH recurrence (HR 0.85 (95% CI 0.57 to 1.25), p=0.41), but with a significantly increased risk of major bleeding (HR 1.66 (95% CI 1.20 to 2.30), p<0.01). Meanwhile, OAC was associated with a reduced risk of ischaemic stroke/systemic thromboembolism (IS/SE) (HR 0.54 (95% CI 0.42 to 0.70), p<0.01) and all-cause death (HR 0.38 (95% CI 0.28 to 0.52), p<0.01) compared with no anticoagulants. Furthermore, compared with warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with a significant reduction of ICH recurrence (HR 0.64 (95% CI 0.49 to 0.85), p<0.01), while the risk of IS/SE and all-cause mortality were comparable between warfarin and NOACs.

Conclusions For patients with AF with prior ICH, OAC is associated with a significant reduction in IS/SE and all-cause mortality without increasing ICH recurrence, but may increase major bleeding risk. Compared with warfarin, NOACs had a better safety profile and comparable efficacy. Further larger RCTs are warranted to validate these findings.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/heartjnl-2023-322492

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • HC, GC and WH are joint first authors.

    • Contributors WH: study concept and design; interpretation of data; statistical analysis; revision of the manuscript; responsible for the overall content as guarantor. HC: data searches and study selection; data extraction and quality assessment; drafting of the manuscript; revision of the manuscript. GC: data searches and study selection; data extraction and quality assessment; drafting of the manuscript. CJ: revision of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.