Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Background: Intracranial hemorrhage (ICH) is excluded in most anticoagulation randomized clinical trials (RCTs), so oral anticoagulant (OAC) therapy is still the conventional treatment for patients with atrial fibrillation (AF) after ICH. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of OAC for these patients. Methods: We systematically searched the PubMed and Embase databases up to March 2022 for RCTs and observational studies exploring the effect of OAC in patients with AF after ICH. The effectiveness outcomes included stroke or systemic embolism, ischemic stroke, and all-cause death, whereas the safety outcomes were major bleeding and recurrent ICH. Hazard ratios (HRs) and 95% confidence intervals (CIs) from each study were pooled using a random-effects model. Results: A total of 14 studies were included. The OAC therapy that was performed reduced the risks of stroke or systemic embolism (HR = 0.65, 95% CI 0.53-0.81), ischemic stroke (HR = 0.70, 95% CI 0.60-0.82), and all-cause death (HR = 0.43, 95% CI 0.27-0.70) but had a higher risk of major bleeding (HR = 1.50, 95% CI 0.94-2.40) and showed no difference in recurrent ICH (HR = 0.91, 95% CI 0.53-1.55) compared to the no OAC therapy. With the use of non-vitamin K antagonist oral anticoagulant (NOAC) therapy, a lower risk of stroke or systemic embolism (HR = 0.83, 95% CI 0.70-0.98), all-cause death (HR = 0.67, 95% CI 0.53-0.84), and recurrent ICH (HR = 0.68, 95% CI 0.54-0.86) was observed against the use of vitamin K antagonists (VKA) therapy. Conclusion: The OAC therapy (especially VKA) revealed superior effectiveness in patients with AF after ICH, and the superiority of NOAC was also found, but some related evidence was limited.