Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study

 

 

 

Nielsen PB, et al. Stroke. 2022 Apr 13;101161STROKEAHA121038331

 

 

 

Introduction

 

심방세동(Atrial fibrillation, AF)은 뇌경색(ischemic stroke)의 매우 중요한 위험인자이기 때문에 AF 환자에서 명확한 기준 하에 경구용 항응고제 치료(oral anticoagulant therapy, OAT)를 사용하는 것이 권장되고 있다. 하지만, 뇌출혈(intracerebral hemorrhage, ICH)이 있었던 AF 환자에서 항응고제 치료에 대해서는 명확한 가이드라인이 없는 실정이다.

 

 

 

Objectives

 

본 연구에서는 심방세동 및 뇌출혈 환자에서 항응고제 치료에 따른 뇌졸중 위험도에 대해 알아보고자 하였다.

 

 

 

Methods

 

• The Danish Stroke Registry에 2003년~2018년까지 등록된 심방세동 환자 중 뇌출혈이 발생한 환자를 대상으로 하였다.

• 경구용 항응고제 치료 정의

  • 뇌출혈 이후 warfarin 또는 NOAC agent를 재처방 받은 경우

• Outcome

 

1. Recurrent ICH

2. Cerebrovascular ischemic events (ischemic stroke, unspecified stroke, or transient ischemic attack)

3. All cause death

 

• 통계 분석:

  • PRESTIGE-AF trial 대상자(No OAC initiation during follow-up)와 비교 분석

  • CHA₂DS₂-VASc score categories에 따라 subgroup analysis 시행

 

 

 

Results

 

• 대상자: 총 1,885명

 

1. CHA2DS2-VASc score 2~3: 603명

2. CHA2DS2-VASc score 4~6: 866명

3. CHA2DS2-VASc score >6: 416

 

• Recurrent intracerebral hemorrhage (Table 1)

  • Recurrent ICH were highest among those initiating/resuming OAC during follow-up.

 

Table 1. Absolute Risk of Recurrent Intracerebral Hemorrhage After 1 Year of Follow-Up in the Subpopulation Not Initiating/Resuming Oral Anticoagulant Therapy During Follow-Up

 

Absolute risk after 1 y of follow-up	Risk % (95% CI)
	No OAC initiation during follow-up	OAC initiation during follow-up
All	1.5 (1.0 to 2.2)	2.8 (1.5 to 4.8)
CHA2DS2-VASc score 2–3	1.2 (0.5 to 2.3)	2.9 (1.0 to 6.9)
CHA2DS2-VASc score 4–6	1.8 (1.1 to 2.9)	2.2 (0.7 to 5.3)
CHA2DS2-VASc score >6	1.4 (0.6 to 3.0)	3.6 (1.2 to 8.4)

 

OAC, Oral Anticoagulant Therapy

 

 

• Cerebrovascular ischemic events (Table 2)

  • Cerebrovascular ischemic events were highest among those initiating/resuming OAC during follow-up.

 

Table 2. Absolute Risk of Cerebrovascular Ischemic Events After 1 Year of Follow-Up in the Subpopulation Not Initiating/Resuming Oral Anticoagulant Therapy During Follow-Up

 

Absolute risk after 1 y of follow-up	Risk % (95% CI)
	No OAC initiation during follow-up	OAC initiation during follow-up
All	2.6 (1.9 to 3.4)	3.2 (1.7 to 5.5)
CHA2DS2-VASc score 2–3	2.4 (1.4 to 3.9)	2.9 (1.0 to 6.9)
CHA2DS2-VASc score 4–6	2.8 (1.8 to 4.1)	3.7 (1.4 to 7.8)
CHA2DS2-VASc score >6	2.5 (1.3 to 4.4)	2.6 (0.7 to 7.0)

 

OAC, Oral Anticoagulant Therapy

 

 

 

 

• All-Cause death

  • All-cause death were lower among those initiating/resuming OAC during follow-up.

 

Table 3. Absolute Risk of All-Cause Death After 1 Year of Follow-Up in the Subpopulation Not Initiating/Resuming Oral Anticoagulant Therapy During Follow-Up

 

Absolute risk after 1 y of follow-up	Risk % (95% CI)
	No OAC initiation during follow-up	OAC initiation during follow-up

 

 

 

 

 

All	30.3 (28.3 to 32.5)	22.0 (17.3 to 27.8)
CHA2DS2-VASc score 2–3	24.8 (21.5 to 28.5)	12.7 (8.0 to 19.9)
CHA2DS2-VASc score 4–6	29.3 (26.3 to 32.5)	28.6 (20.1 to 39.6)
CHA2DS2-VASc score >6	40.7 (36.1 to 45.6)	20.0 (13.6 to 29.0)

 

OAC, Oral Anticoagulant Therapy

 

Conclusions

 

본 연구 결과를 통해 AF을 동반한 뇌출혈 환자에서는 경구용 항응고제 치료를 다시 시작하였을 때 그렇지 않은 경우에 비해 뇌출혈 재발 및 허혈성 뇌졸중 발생은 증가하지만, 사망률이 더 낮은 것을 알 수 있었다. 향후 추가적인 전향적 연구를 통해 AF을 동반한 뇌출혈 환자에서 보다 명확한 뇌졸중 예방 치료 방법의 제시가 필요하다.