Should anticoagulation be restarted after ICH for stroke prevention in atrial fibrillation?

Edip Gurol, MD, Massachusetts General Hospital and Harvard Medical School, Boston, MA, shares his stance on the major ongoing debate surrounding the use of anticoagulants for secondary prevention in patients with atrial fibrillation after an intracerebral hemorrhage (ICH). Occurrence of a first ICH increases an individual’s risk of a second brain bleed 15-fold. Data from several studies indicates that restarting anticoagulation treatment after ICH is associated with a much higher rate of repeat brain bleed and mortality. Based on initial studies, even in low-risk patients, oral anticoagulants increase the risk of a repeat brain bleed in patients with atrial fibrillation by around 2-5-fold. A study from the UK (NCT03153150) investigated the use of anticoagulants in 200 patients with ICH and atrial fibrillation revealed that patients receiving anticoagulants were 5 times more likely to have a repeat brain bleed than patients not receiving any treatment. Another major study, APACHE-AF (NCT02565693), observed similar results in the 100-patient cohort. Another important outcome of these studies was that the mortality rate of patients on anticoagulants was around 70% when a second brain bleed occurred. Dr Gurol highlights alternatives to anticoagulation treatment, such as left atrial appendage closure. This interview took place at the American Academy of Neurology 2022 Congress in Seattle, WA.