Department of Neurology and Neurosurgery, UMC Utrecht Stroke Centre, Rudolf Magnus Institute of Neurosciences, University Medical Centre Utrecht, Utrecht, The Netherlands.
Cerebrovasc Dis. 2013;36(1):33-7. doi: 10.1159/000351151. Epub 2013 Jul 30.
For patients who survive intracerebral haemorrhage (ICH) during treatment with oral anticoagulation (OAC), the balance between the benefits and risks of restarting OAC is unclear. The decision to restart OAC or to start antiplatelet therapy in these patients therefore poses a dilemma for all physicians involved. We assessed the long-term outcome of patients who did or did not restart antithrombotic therapy after OAC-associated ICH.
We conducted a retrospective follow-up study of all patients discharged from our institution after OAC-associated ICH over a 10-year period. Data on the use of OAC or platelet inhibitors and the occurrence of vascular events during follow-up were assessed through questionnaires and patient files. The primary outcome was recurrent fatal or non-fatal stroke. Secondary outcomes were the occurrence of other haemorrhagic, thrombotic or thromboembolic events. With patients without antithrombotic treatment as reference, we calculated incidence ratios with corresponding 95% confidence intervals (CI) for treatment with OAC and for treatment with antiplatelet therapy.
We included 38 patients, of whom 21 (55%) died during a mean follow-up of 3.5 years. The medication regime changed frequently during follow-up, illustrated by the fact that two thirds of the patients who had resumed OAC within 2 months of ICH terminated this at later points in time. Two recurrent strokes occurred during 35.4 patient-years without antithrombotic medication, 7 during 63.8 patient-years on antiplatelet medication (incidence ratio 1.9; 95% CI, 0.4-9.4), and 3 during 19.5 patient-years on OAC (incidence ratio 2.7; 95% CI, 0.5-16.3). There was only 1 recurrent ICH, which occurred during treatment with OAC.
In this observational study, no significant difference in the primary outcome measure was found between the treatment groups, but there was a tendency towards a higher long-term risk of any stroke in patients who resumed OAC or started antiplatelet therapy. However, based on these results it is difficult to draw any concrete conclusions or make any strong recommendations. A randomized trial to assess the optimal long-term strategy after OAC-related ICH is warranted. Based on the point estimates of our study, such a trial should involve at least 300 patient-years of follow-up.
对于接受口服抗凝治疗（OAC）期间发生颅内出血（ICH）并幸存的患者，重新开始 OAC 的获益与风险之间的平衡尚不清楚。因此，对于所有相关医生来说，决定是否重新开始 OAC 或开始抗血小板治疗都存在两难困境。我们评估了在 OAC 相关 ICH 后是否重新开始抗血栓治疗的患者的长期预后。
我们对过去 10 年间在我们机构出院的所有 OAC 相关 ICH 患者进行了回顾性随访研究。通过问卷和患者病历评估了 OAC 或血小板抑制剂的使用情况以及随访期间血管事件的发生情况。主要结局是复发性致命或非致命性卒中。次要结局是其他出血、血栓或血栓栓塞事件的发生。以未接受抗血栓治疗的患者为参照，我们计算了使用 OAC 和抗血小板治疗的发生率比及其相应的 95%置信区间（CI）。
我们纳入了 38 例患者，其中 21 例（55%）在平均 3.5 年的随访期间死亡。在随访过程中，治疗方案经常发生变化，例如，2/3 的患者在 ICH 后 2 个月内重新开始 OAC，但后来在不同时间停止了治疗。在没有抗血栓治疗的 35.4 患者-年期间发生了 2 次复发性卒中，在 63.8 患者-年的抗血小板治疗期间发生了 7 次（发生率比 1.9；95%CI，0.4-9.4），在 19.5 患者-年的 OAC 治疗期间发生了 3 次（发生率比 2.7；95%CI，0.5-16.3）。只有 1 例复发性 ICH 发生在 OAC 治疗期间。
在这项观察性研究中，各组之间主要结局指标无显著差异，但在重新开始 OAC 或开始抗血小板治疗的患者中，长期任何卒中的风险有升高趋势。然而，基于这些结果，很难得出任何具体的结论或做出任何强烈的建议。有必要开展一项评估 OAC 相关 ICH 后最佳长期策略的随机试验。基于我们研究的点估计，这样的试验应至少包含 300 患者-年的随访。
