Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2017 Jun;48(6):1594-1600.
doi: 10.1161/STROKEAHA.116.016327. Epub 2017 Apr 17.

Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis

Santosh B Murthy  1 , Ajay Gupta  2 , Alexander E Merkler  2 , Babak B Navi  2 , Pitchaiah Mandava  2 , Costantino Iadecola  2 , Kevin N Sheth  2 , Daniel F Hanley  2 , Wendy C Ziai  2 , Hooman Kamel  2
Affiliations
Meta-Analysis

Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis

Santosh B Murthy et al. Stroke. 2017 Jun.

Abstract

Background and purpose: The safety and efficacy of restarting anticoagulation therapy after intracranial hemorrhage (ICH) remain unclear. We performed a systematic review and meta-analysis to summarize the associations of anticoagulation resumption with the subsequent risk of ICH recurrence and thromboembolism.

Methods: We searched published medical literature to identify cohort studies involving adults with anticoagulation-associated ICH. Our predictor variable was resumption of anticoagulation. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between anticoagulation resumption and our outcomes.

Results: Eight studies were eligible for inclusion in the meta-analysis, with 5306 ICH patients. Almost all studies evaluated anticoagulation with vitamin K antagonists. Reinitiation of anticoagulation was associated with a significantly lower risk of thromboembolic complications (pooled relative risk, 0.34; 95% confidence interval, 0.25-0.45; Q=5.12, P for heterogeneity=0.28). There was no evidence of increased risk of recurrent ICH after reinstatement of anticoagulation therapy, although there was significant heterogeneity among included studies (pooled relative risk, 1.01; 95% confidence interval, 0.58-1.77; Q=24.68, P for heterogeneity <0.001). No significant publication bias was detected in our analyses.

Conclusions: In observational studies, reinstitution of anticoagulation after ICH was associated with a lower risk of thromboembolic complications and a similar risk of ICH recurrence. Randomized clinical trials are needed to determine the true risk-benefit profile of anticoagulation resumption after ICH.

Keywords: anticoagulation; atrial fibrillation; myocardial infarction; stroke; thromboembolism.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest: None.

Figures

Figure 1
Figure 1
Forest plot of the association between resumption of oral anticoagulation therapy and arterial thromboembolic complications after intracranial hemorrhage. The meta-analysis was calculated using a random-effects model, with the pooled relative risk shown in the forest plot. Each square represents the point estimate of any given study’s effect size. The size of the squares is proportional to the inverse of the variance of the estimate, while the horizontal lines represent each study’s 95% confidence intervals. The diamond represents the pooled estimate with the width of the diamond representing the pooled 95% CI. Heterogeneity: Q = 5.12; P = 0.28.
Figure 2
Figure 2
Forest plot of the association between resumption of oral anticoagulation therapy and recurrence of intracranial hemorrhage. The meta-analysis was calculated using a random-effects model, with the pooled relative risk shown in the forest plot. Heterogeneity: Q = 24.68; P <0.001.
See this image and copyright information in PMC

Comment in

References

    1. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the u.S. Adult population. Am J Cardiol. 2013;112:1142–1147. - PubMed
    1. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Annals of internal medicine. 2007;146:857–867. - PubMed
    1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Guyton RA, et al. 2014 aha/acc guideline for the management of patients with valvular heart disease: A report of the american college of cardiology/american heart association task force on practice guidelines. J Thorac Cardiovasc Surg. 2014;148:e1–e132. - PubMed
    1. Flaherty ML, Kissela B, Woo D, Kleindorfer D, Alwell K, Sekar P, et al. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology. 2007;68:116–121. - PubMed
    1. Garcia-Rodriguez LA, Gaist D, Morton J, Cookson C, Gonzalez-Perez A. Antithrombotic drugs and risk of hemorrhagic stroke in the general population. Neurology. 2013;81:566–574. - PubMed

MeSH terms