Oral Anticoagulant Therapy in Patients with Atrial Fibrillation After Intracranial Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Background The management of atrial fibrillation (AF) in patients with a history of intracranial hemorrhage (ICH) presents a significant clinical challenge. Although oral anticoagulants (OACs), have been shown to effectively reduce thromboembolic events in AF patients, their use in survivors of ICH raises concerns regarding the risk of recurrent bleeding. In this study, we conduct a systematic review of randomized controlled trials (RCTs) to assess the safety and efficacy of OAC therapy in AF patients following ICH. Methods We searched PubMed/Embase for RCTs assessing OACs in AF patients with ICH history. Efficacy outcomes included ischemic stroke, major vascular events, stroke or vascular death, major embolic events, and all-cause mortality. Results A total of three RCTs with 623 participants were included. Compared to no anticoagulation or antiplatelet therapy alone, OAC did not significantly reduce the risk of ischemic stroke (HR = 0.27, 95% CI 0.02, 3.92, P = .13), but it significantly reduced the occurrence of major vascular events (HR = 0.65, 95% CI 0.43, 0.98, P = .04). However, OACs significantly increased the risk of recurrent ICH (HR = 4.05, 95% CI 1.62, 10.17, P = .003) and major bleeding events (HR = 3.70, 95% CI 1.64, 8.35, P = .002). No significant effect was observed on stroke or vascular death (HR = 0.74, 95% CI 0.39, 1.41, P = .36). Conclusions OACs can reduce the risk of major vascular events, but they significantly increase the risk of bleeding, particularly recurrent ICH. Clinical decision-making should be individualized, carefully evaluating the thromboembolic and bleeding risks for each patient. Further high-quality RCTs are needed to validate these findings.