Patients hospitalized for intracerebral hemorrhage (ICH) were more likely to die before discharge if they had prior oral anticoagulant use, a study showed.
In-hospital mortality rates reached 32.6% for those who had been on warfarin (Coumadin), 26.5% for those on non-vitamin K antagonist oral anticoagulants (NOACs), and 22.5% among patients with no history of oral anticoagulation use.
Multivariable adjustment confirmed that death was more likely for patients with prior use of warfarin (adjusted OR 1.62, 95% CI 1.53-1.71) or NOACs (adjusted OR 1.21, 95% CI 1.11-1.32), according to Gregg Fonarow, MD, of Ronald Reagan UCLA Medical Center, and colleagues in the Journal of the American Medical Association.
Compared with patients who had used warfarin in the past, those who had been on NOACs had a lower risk of in-hospital mortality (adjusted OR 0.75, 95% CI 0.69-0.81). This difference in mortality was especially prominent in the pool with prior use of dual antiplatelet agents (32.7% NOACs versus 47.1% warfarin, adjusted OR 0.50, 95% CI 0.29-0.86).
“NOACs might be a better option in broader clinical situations, given the risk of worse outcomes of ICH with supratherapeutic INR [international normalized ratio] … and the challenge in achieving time in therapeutic range with warfarin,” the investigators suggested.
Fonoarow’s group noted that in this retrospective cohort study of ICH patients (n=141,311) admitted at 1,662 Get With The Guidelines-Stroke participating hospitals, 10.6% of participants had taken warfarin before; 3.5%, NOACs; 28.0%, a concomitant single antiplatelet agent; and 4.1%, dual antiplatelet therapy.
Acute ICH stroke severity was no different among the warfarin, NOAC, and no oral anticoagulation groups. However, patients with prior use of warfarin or NOACs were older and were more likely to have atrial fibrillation and prior stroke.
Hence, the possibility of residual confounding is a major caveat to the present analysis, the authors acknowledged, adding that the generalizability of their findings may be limited due to the selected group of participating sites. Moreover, the timing of last anticoagulant or antiplatelet use was unknown.
Fonarow reported serving on the Get With The Guidelines steering committee; receiving grant funding from the Patient Centered Outcome Research Institute; being an employee of the University of California, which has a patent on an endovascular therapy device; and having a financial relationship with Janssen.