Ying Gue, PhD

Zhou E, Lord A, Boehme A, Henninger N, de Havenon A, Vahidy F, Ishida K, Torres J, Mistry EA, Mac Grory B, et al. Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage. Stroke. 2020;51:3592–3599.

Zhou et al. reported a retrospective study using the California State Inpatient Database to compare the risk of ischemic stroke in patients with atrial fibrillation (AF) after extracranial hemorrhage (ECH). Extracting data from 2005 to 2011, they identified a total of 764,257 patients with AF in which 98,647 (13.3%) had an admission with extracranial hemorrhage. The primary outcome of interest, which was re-hospitalization with an acute ischemic stroke after index admission for ECH and after first hospitalization for control patients, occurred in 22,748 (3.4%) patients.

Kaplan-Meier analysis indicated that patients with ECH had lower stroke-free survival probability when compared to patients without ECH (hazard ratio [HR] 1.15, 95% CI 1.11 – 1.19 in the unadjusted model). This difference persisted even with adjustments of potential confounders (age, gender, medical history and CHA2DS2-VASc score). 

Unfortunately, due to the limitations of the database, the authors were unable to comment on anticoagulation status both before and after ECH. This is an important limitation to highlight as the hypothesis that the increase in ischemic stroke was due to withholding oral anticoagulants (OAC) following an ECH, although logical, cannot be proven. Comparison to understand the bleeding risks in these patients would also be of interest as understanding the risk of restarting anticoagulation may be useful in counselling these high-risk patients.

Within its limitations, this study highlights that the persistent risk of embolic events in patients with AF exists even after ECH and the potential long-term harm in stopping OAC in these patients. OAC should be reinitiated once the patient is stabilized and the bleeding source has been dealt with, provided that the risk and benefit have been reevaluated and discussed with the patient. This emphasizes the need for regular reevaluation of the treatment of patients with AF, especially so if the clinical condition changes.