Rajbeer S. Sangha, MD

Alonso A, Bengtson LGS, MacLehose RF, Lutsey PL, Chen LY, and Lakshminarayan K. Intracranial Hemorrhage Mortality in Atrial Fibrillation Patients Treated With Dabigatran or Warfarin. Stroke. 2014

Warfarin has long been the agent of choice for the reduction of ischemic stroke secondary to AF.  Recently, new anticoagulant agents including dabigatrin, rivoxaraban and apixaban have been approved by the FDA for the reduction of stroke secondary to AF.  While these agents may be more effective in the reduction of stroke, the lack of commercially-available antidotes has been a limitation and a noted major disadvantage.  The authors of this study did a retrospective analysis of healthcare utilization date, in-hospital mortality in atrial fibrillation (AF) patients using oral anticoagulants who presented with intracranial bleeding (ICB).

Alonso et al. analyzed 2391 patients with AF who were admitted with ICB (2290 on warfarin and 101 on dabigatran), looking for in hospital mortality.  The results showed that in hospital mortality was similar in patients who were originally on warfarin (22%) vs dabigatran (20%).  Further statistical analysis showed that the propensity score-adjusted RR of morality in dabigatran users was 0.93.  The associations were similar for all varying subtypes of ICB.  Likely, due to a lack of data for all the patients the authors were not able to conduct analysis of patient outcomes following discharge and had to limit the study to in-hospital mortality. 

The authors of this study address an important issue which is at the center of debate for the prevention of stroke secondary to atrial fibrillation.  While the number of patients being analyzed in this analysis for dabigatran are low (101) – which the authors also recognize – the analysis is consistent with the RE-LY trial (Dabigatran versus Warfarin in patients with atrial fibrillation).  It would have been interesting however to see the analysis of patients regarding their outcomes of mortality in a one year period as well as three month outcomes of modified rankin scale.   Clinicians should continue to weigh this data when choosing an anti-coagulant while we await a commercially-available antidote.