Prior use of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin is associated with a higher risk for in-hospital mortality compared with no NOAC or warfarin use in patients with intracerebral hemorrhage (ICH), whereas prior NOAC use alone vs warfarin is associated with a lower risk for in-hospital mortality, according to retrospective findings published in JAMA.
In this cohort study, investigators evaluated 141,311 patients with ICH who were included in the ongoing American Heart Association/American Stroke Association Get With the Guidelines-Stroke (GTWG-Stroke) registry database. The researchers compared patients with prior use of OAC or antiplatelet agents (medication use ≤7 before admission) with patients with no use history to assess for differences in in-hospital mortality. For the purposes of this study, researchers compared patients taking warfarin (n=15,036 [10.6%]), NOACs before ICH (n=4918 [3.5%]), or concomitant single- and dual-antiplatelet agents (n=5783 [4.1%]).
In-hospital mortality was higher in patients who had a history of NOAC (adjusted risk difference [ARD], 3.3% [97.5% CI, 1.7%-4.8%]; adjusted odds ratio [AOR] 1.21 [97.5% CI, 1.11-1.32]) and prior warfarin use (ARD, 9.0% [97.5% CI, 7.9%-10.1%]; AOR, 1.62 [97.5% CI, 1.53-1.71]) compared with patients without a history of taking OACs. Baseline comorbidities may explain these findings, as patients with a history of NOAC or warfarin use were generally older and more often presented with atrial fibrillation and a history of stroke or transient ischemic attack.
Patients with a history of NOAC use had a lower risk for in-hospital mortality compared with patients with prior warfarin use (ARD, −5.7% [97.5% CI, −7.3% and −4.2%]; AOR, 0.75 [97.5% CI, 0.69-0.81]). In addition, the mortality difference between patients with a history of warfarin and NOAC use was nonsignificantly greater in patients with a use history of dual-antiplatelet therapies (32.7% vs 47.1%; ARD, −15.0% [95.5% CI, −26.3% to −3.8%]; AOR, 0.50 [97.5% CI, 0.29-0.86]) vs patients without prior antiplatelet therapy use (26.4% vs 31.7%; ARD, −5.0% [97.5% CI, −6.8% to −3.2%]; AOR, 0.77 [97.5% CI, 0.70-0.85]; P =.07).
Future trials with a randomized and double-blind design may help reduce bias that was possibly inherent in this study. In addition, studies using real-world patients outside of the GWTG-Stroke registry database may provide greater insight into the association between NOAC and warfarin use and in-hospital mortality in the overall ICH population.
The investigators’ findings emphasize the cost-effective benefits “of NOACs by showing that ICH outcomes are less severe among patients with prior use of NOACs compared with patients with prior use of warfarin.”
Inohara T, Xian Y, Liang L, et al. Association of intracerebral hemorrhage among patients taking non-vitamin K antagonist vs vitamin K antagonist oral anticoagulants with in-hospital mortality [published online January 25, 2018]. JAMA. doi: 10.1001/jama.2017.21917