NYU Grossman School of Medicine, New York, NY (E.Z.).
Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.).
Stroke. 2020 Dec;51(12):3592-3599. doi: 10.1161/STROKEAHA.120.029959. Epub 2020 Oct 8.
Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH).
We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHADS-VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer.
We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11-1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years.
Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.
抗凝治疗不仅降低了心房颤动（AF）患者发生缺血性中风的风险，还使患者易发生出血性并发症。关于 AF 患者在发生颅外出血（ECH）后首次发生缺血性中风的风险，我们知之甚少。
我们使用加利福尼亚州住院患者数据库进行了一项回顾性研究，该数据库纳入了 2005 年至 2011 年加利福尼亚州所有非联邦医院的住院患者。暴露变量为因 ECH 住院且之前有 AF 诊断。结局变量为在随访期间及每 6 个月发生急性缺血性中风的住院情况。我们排除了在 ECH 诊断前或同时发生中风的患者。我们使用 Cox 回归模型，在调整了相关人口统计学和合并症后，计算了随访期间和每 6 个月发生缺血性中风的校正风险比。在亚组分析中，根据 ECH 的主要诊断、ECH 的严重程度/类型、年龄、CHADS-VASc 评分、是否患有胃肠道或泌尿生殖系统癌症对受试者进行分层。
我们确定了 764 257 名无中风病史的 AF 患者（平均年龄 75 岁，49%为女性）。其中 98 647 名（13%）患者有 ECH 相关住院史，22 748 名（3%）患者在研究期间发生了缺血性中风。与没有 ECH 的患者相比，ECH 患者发生缺血性中风的风险增加了 ≈15%（总体校正风险比为 1.15[95%置信区间，1.11-1.19]）。这种风险似乎在 ECH 后的至少 18 个月内仍持续升高。在亚组分析中，ECH 的主要入院诊断为 ECH、ECH 严重程度/类型、胃肠道类型 ECH、患有胃肠道或泌尿生殖系统癌症、年龄≥60 岁的患者风险最高。
因 ECH 住院的 AF 患者未来发生缺血性中风的风险可能略有增加。在这一脆弱人群中，应特别注意权衡抗凝治疗的获益与风险以及使用非抗凝替代方法（如左心耳封堵术）之间的最佳平衡。
