NEW ORLEANS -- The size of the brain bleed appears to determine which medications, if any, are given to atrial fibrillation patients after an intracerebral hemorrhage, a retrospective study showed.
Patients with a brain bleed that averaged 2.39 cc were started on warfarin post bleed; those with an average brain bleed of 8.56 cc received anti-platelet therapy, but those who had an average hemorrhage size of 28.9 cc were given no treatment post bleed (P=0.04 for both comparisons), according to Nicholas Perros, BA, a second-year medical student at Loyola University Medical Center in Maywood, Ill.
Action Points
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
- This single-center retrospective study found that the size of a hemorrhagic stroke appeared to determine whether warfarin, anti-platelet agents, or no anti-thrombotic therapy was restarted in patients with atrial fibrillation.
- Note that those with the smallest hemorrhage were given warfarin, those with an intermediate-size hemorrhage were given anti-platelet drugs, and those with a larger-size hemorrhage were given no anti-thrombotics -- and all of these differences were statistically significant.
"Patients with atrial fibrillation require anticoagulation therapy to prevent ischemic strokes," Perros told 番茄社区 at his poster presentation at the American Academy of Neurology meeting. "However, patients with atrial fibrillation on anti-thrombotic drugs are at high risk for hemorrhagic stroke."
Basically, he said, survivors of these brain bleeds are caught between a rock and a hard place: They still need anti-thrombotic therapy due to unresolved atrial fibrillation, yet they are at risk of another intracerebral hemorrhage.
In the 73 patient charts Perros reviewed, 45 patients survived. Of the survivors, 25 were on warfarin prior to their hemorrhagic stroke; 11 were on warfarin plus an anti-platelet agent, and nine were treated with anti-platelet agents only.
After the bleed resolved, 12 patients were restarted on warfarin; 18 were put on anti-platelet medication, and 13 were not medicated. Two other patients experienced second strokes – one ischemic, one hemorrhagic. Both had been on warfarin on admission, but neither received medication at the time of the subsequent stroke.
"We do try to get patients back on anticoagulants as quickly as possible," commented Ralph Sacco, MD, chairman of neurology at the University of Miami and a spokesman for the American Heart Association/American Stroke Association.
"It depends on how big the hemorrhage is, whether it is worsening, and other factors relating to the initial hemorrhage," Sacco told 番茄社区. "Whether they are put back on medication may also depend on the type of hemorrhagic stroke, which is not defined in this study."
Sacco said that usually clinicians will delay the restart of anti-thrombotic measures until serial CT scans and other clinical factors are evaluated. "The idea is to determine if the benefit of anticoagulation is greater than the risk of a further bleed," he said.
Perros said that he also found a borderline significance in the age of the patients as far as restarting anti-thrombotic therapy. Those who did not receive medication had an average age of 81, while those on warfarin were about 72 years of age and those on anti-platelet therapy were about 77 years of age (P=0.09 for both).
He found no significant differences with regard to gender, smoking history, or a history of coronary artery disease or congestive heart failure.
"The timing of the resumption of anti-thrombotic therapy needs to be explored in future prospective studies," Perros suggested.
Disclosures
Perros had no disclosures. Sacco had no disclosures.
Primary Source
American Academy of Neurology
Source Reference: Perros N, et al "Resumption of antithrombotic therapy following hemorrhagic stroke in patients with atrial fibrillation" AAN 2012.