Anticoagulation in Patients With Atrial Fibrillation in the Setting of Prior Hemorrhage
An Ongoing Dilemma
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See releated articles, pp 2653, 2660, 2665, 2671
A clinician needs to counsel a patient with atrial fibrillation on the advisability of resuming anticoagulation after a parenchymal brain hemorrhage resulting in a persistent, albeit nondisabling functional impairment. The issue to be addressed is straightforward; the advice to be offered, however, is far from clear. Relevant prospective, randomized controlled trials are lacking,1,2 and the vagaries of providing recommendations based on observational studies and experience (eminence-based medicine) often lead to choices that are later refuted when adequately tested. This is, in part, because historic event rates in populations can change over time,3,4 and conclusions from observational studies can be affected by several biases.5 Causing further uncertainty, the results of case–control and other nonrandomized studies may be contradictory because of differences in cohort characteristics and unmeasured confounding.6 Yet, the patient cannot await the collection of the high-quality data required to support more definitive guidance.
Healthcare providers turn to authoritative clinical guidelines to review current evidence-based opinions for patient evaluation and management. The American College of Chest Physicians guidelines indicate that, “In patients with a history of a symptomatic primary intracerebral hemorrhage, we suggest against the long-term use of antithrombotic therapy for the prevention of ischemic stroke.”1 The writers, however, remark that patients might benefit from antithrombotic therapy if they are at relatively low risk of recurrent intracerebral hemorrhage (ICH) and relatively high risk (>7% per year) of thromboembolic events. Similarly, the American Heart Association/American Stroke Association secondary stroke prevention guidelines suggest that, “The decision to restart antithrombotic therapy after intracerebral hemorrhage related to antithrombotic therapy depends on the risk of subsequent arterial or venous thromboembolism, the risk of recurrent ICH, and the overall status of the patient and must, therefore, be …