Outcomes of Reinitiating Direct Oral Anticoagulants After Intracranial Hemorrhage: A Sequential Target Trial Emulation Study (JACC Asia March 2025)-Article: Outcomes of Reinitiating Direct Oral Anticoagulants After Intracranial Hemorrhage: A Sequential Target Trial Emulation Study

Article: Outcomes of Reinitiating Direct Oral Anticoagulants After Intracranial Hemorrhage: A Sequential Target Trial Emulation Study

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This study investigates the effectiveness and safety of reinitiating direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients who survived an intracranial hemorrhage (ICH) event. Using Taiwan's National Health Insurance claims data, the study included AF patients on antithrombotic therapy who experienced ICH between June 2012 and December 2018. DOAC reinitiation post-ICH was assessed at six consecutive 14-day intervals following discharge, stratified by the stroke severity index to explore optimal timing.<br /><br />Results showed that DOAC reinitiation is associated with a reduced risk of all-cause mortality (adjusted hazard ratio [aHR]: 0.73) without increasing the risk of recurrent ICH (aHR: 1.21) compared to no antithrombotic therapy. The risk of ischemic stroke (IS) was similar between both groups (aHR: 0.73). Reinitiation of DOACs provided the most benefit to patients with low ICH severity when done within 14 days post-discharge, and for those with high ICH severity when reinitiated between 14 and 28 days post-discharge.<br /><br />This study suggests that DOACs can be safely reinitiated in AF patients after ICH, with timing adjusted based on the severity of the initial hemorrhage. Reinitiating DOACs is recommended within 14 days post-discharge for patients with lower ICH severity, whereas a delay until 28 days is suggested for those with higher severity to optimize treatment outcomes in terms of mortality and ischemic event risk. The study’s design, a sequential target trial emulation, helps mitigate biases in observational studies, offering more reliable insights into post-ICH management strategies. However, it noted limitations including a lack of detailed clinical data on ICH and a relatively modest statistical power due to the specific patient population studied. This research highlights the need for personalized timing strategies in reinitiating DOAC therapy post-ICH, contributing essential evidence for clinical decision-making for AF patients in similar scenarios.

Keywords

DOAC reinitiation

intracranial hemorrhage

atrial fibrillation

antithrombotic therapy

stroke severity index

mortality risk

ischemic stroke

sequential target trial emulation

personalized treatment

clinical decision-making