Zhou Qiang, Liu Xiang, Yang Xian, Huang Xiao-Hui, Wu Yan-Zi, Tao Ying-Ying, Wei Meng
Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China.
Front Pharmacol. 2023 Mar 9;14:1122564. doi: 10.3389/fphar.2023.1122564. eCollection 2023.
The benefits and risks of starting anticoagulation therapy, such as direct oral anticoagulations (DOACs) or warfarin, in atrial fibrillation (AF) patients with a history of intracranial hemorrhage (ICH) remain controversial. We performed a systematic review and meta-analysis to compare the safety and efficacy of starting oral anticoagulation (OAC) and non-oral anticoagulation in these patients. PubMed, Cochrane Library, and Embase were searched from inception to 01 May 2022 for randomized controlled trials and cohort studies, reporting effectiveness and safety outcomes for anticoagulation therapy in atrial fibrillation patients with intracranial hemorrhage. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration tool were used to evaluate bias risks for all randomized controlled trials (RCTs) and cohort studies. An effects model was applied to calculate adjusted hazard ratios (aHRs) for randomized controlled trials and cohort studies. We analyzed data from two randomized controlled trials (304 patients) and seven Cohort studies (17,477 patients). Compared to non-oral anticoagulation, starting oral anticoagulation therapy reduced the risk of Ischemic Stroke/Systemic Embolism (SE) (aHR: 0.64, 95% CI: 0.55-0.57) and all-cause death (aHR: 0.53, 95% CI: 0.35-0.80) in atrial fibrillation patients and a prior history intracranial hemorrhage. Starting oral anticoagulation therapy did not increase the risk of recurrent intracranial hemorrhage (aHR: 1.07, 95% CI: 0.66-1.74), but increased the risk of major bleeding (aHR: 1.38, 95% CI: 1.00-1.91) than no oral anticoagulation therapy. The DOACs had a lower risk of Ischemic Stroke/SE (aHR: 0.84, 95% CI: 0.70-1.00), recurrent intracranial hemorrhage (aHR: 0.63, 95% CI: 0.49-0.82), and all-cause death (aHR: 0.65, 95% CI: 0.48-0.88) compared to warfarin. According to subgroup analyses, starting oral anticoagulation therapy have a higher risk of recurrent intracranial hemorrhage than non-oral anticoagulation therapy (aHR: 1.57, 95% CI: 1.36-1.81) for Asians. After intracranial hemorrhage in atrial fibrillation patients, restarting or initiating oral anticoagulation therapy decreased the risk of Ischemic Stroke/SE and all-cause death but did not increase the risk for recurrent intracranial hemorrhage. Direct oral anticoagulations have better efficacy and safety than warfarin if oral anticoagulation therapy is started. However, starting oral anticoagulation increases the risk for recurrent intracranial hemorrhage in the Asian region.
对于有颅内出血（ICH）病史的心房颤动（AF）患者，启动抗凝治疗（如直接口服抗凝剂（DOACs）或华法林）的益处和风险仍存在争议。我们进行了一项系统评价和荟萃分析，以比较这些患者启动口服抗凝（OAC）和非口服抗凝的安全性和有效性。从创刊至2022年5月1日，检索了PubMed、Cochrane图书馆和Embase，以查找随机对照试验和队列研究，报告有颅内出血的心房颤动患者抗凝治疗的有效性和安全性结果。使用纽卡斯尔-渥太华量表（NOS）和Cochrane协作工具来评估所有随机对照试验（RCT）和队列研究的偏倚风险。应用效应模型计算随机对照试验和队列研究的调整后风险比（aHRs）。我们分析了两项随机对照试验（304例患者）和七项队列研究（17477例患者）的数据。与非口服抗凝相比，启动口服抗凝治疗降低了有颅内出血病史的心房颤动患者发生缺血性卒中/全身性栓塞（SE）的风险（aHR：0.64，95%CI：0.55-0.57）和全因死亡风险（aHR：0.53，95%CI：0.35-0.80）。启动口服抗凝治疗并未增加复发性颅内出血的风险（aHR：1.07，95%CI：0.66-1.74），但与未进行口服抗凝治疗相比，增加了大出血风险（aHR：1.38，95%CI：1.00-1.91）。与华法林相比，DOACs发生缺血性卒中/SE（aHR：0.84，95%CI：0.70-1.00）、复发性颅内出血（aHR：0.63，95%CI：0.49-0.82）和全因死亡（aHR：0.65，95%CI：0.48-0.88）的风险更低。根据亚组分析，对于亚洲人，启动口服抗凝治疗比非口服抗凝治疗有更高的复发性颅内出血风险（aHR：1.57，95%CI：1.36-1.81）。心房颤动患者颅内出血后，重新启动或启动口服抗凝治疗可降低缺血性卒中/SE和全因死亡风险，但不会增加复发性颅内出血风险。如果启动口服抗凝治疗，直接口服抗凝剂比华法林具有更好的疗效和安全性。然而，在亚洲地区启动口服抗凝治疗会增加复发性颅内出血的风险。
