Restarting DOACs After tICH in NVAF

By Patrick Daly - Last Updated: November 21, 2022

After traumatic intracranial hemorrhage (tICH), the optimal time to restart direct oral anticoagulants (DOACs) for patients with nonvalvular atrial fibrillation (NVAF) is unknown, according to a study in World Neurosurgery: X.

The study’s authors examined stroke rates while pausing DOACs, hemorrhage events after restarting anticoagulation, as well as factors associated with deciding to restart DOACs. They found that holding DOACs for 1 month in NVAF was sufficient to reduce the risk of stroke after a tICH.

Early Restart of DOACs After tICH Appears Feasible

This study retroactively reviewed 28 patients on DOACs who presented to the authors’ center with tICH. Recurrent hemorrhage and stroke was evaluated against the following patient characteristics: age, sex, DOAC use, antiplatelet use, congestive heart failure, hypertension, diabetes, previous stroke, vascular disease, sex score for stroke risk in NVAF, injury mechanism, bleeding pattern, Injury Severity Score, use of a reversal agent, Glasgow Coma Scale at 24 hours, hemorrhage expansion, neurosurgical intervention, Morse Fall Risk, DOAC restart date, rebleed events, and ischemic stroke.

Among the cohort, the most common cause of tICH was fall at 89.3% and the most predominant bleeding pattern was subdural hematoma at 60.7%. A total of 16 (64%) out of 25 surviving patients restarted DOAC after tICH at a meedian of 29.5 days.

One patient had recurrent hemorrhage after restarting anticoagulation and one patient experienced an embolic stroke after 118 days off anticoagulation. In addition, variables that influenced the decision indefinitely pause DOACs were age over 80 years, Injury Severity Score ≥16, and expansion of tICH.

Overall, the authors suggested that, “compared with sICH, tICH is a provoked event and anticoagulation may be able to be resumed earlier.” They noted that further research is required to determine the optimal timing to restart DOACs, but summarized that, “based on our data and available literature, it may be reasonable to hold anticoagulation for 1 month after index tICH after confirming hemorrhage stability.”

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