Antiplatelet drugs resumption after antiplatelet-related intracerebral hemorrhage

Abstract

BACKGROUND: Antiplatelet resumption in survivors of antiplatelet-related intracerebral hemorrhage (AICH) represents an important medical dilemma as these patients have a high risk for recurrent intracerebral hemorrhage (ICH) and ischemic vascular event. The increased risk and high mortality of recurrent ICH is a significant factor that leads to the reluctance among clinicians to resume antiplatelet. METHODS: Medical records of survivors of AICH with standard indication for antiplatelet namely coronary artery disease, ischemic stroke and atrial fibrillation, admitted to our hospital from July 2002 till June 2010 were reviewed. The primary end point was vascular death (death due to recurrent ICH or ischemic vascular event). Other end points were recurrent ICH and ischemic vascular event. Univariate hazard ratio for vascular death and recurrent ICH were derived from a Cox proportional hazards model. RESULTS: There were 96 survivors. The mean age was 72.9 years. Thirty five patients (36.5%) were subsequently prescribed antiplatelet (Aspirin=33, Clopidegrol=2), in which 13 were prescribed after an ischemic vascular event. Among antiplatelet users, there were 3 vascular death (rate, 29.8 per 1000 patient-years;95% confidence interval (CI):6.1-87.0), 4 recurrent ICH (rate, 39.7;95% CI:10.8-101.6) and 5 ischemic vascular events (rate, 61.1;95% CI:19.8-142.5). Among non-antiplatelet users, there were 7 vascular death (rate, 26.1 per 1000 patient-years;95% CI:10.5-53.7), 4 recurrent ICH (rate, 15.4;95% CI:4.2-39.4) and 25 ischemic vascular events (rate, 101.9;95% CI:66.0-150.5). Antiplatelet exposure was not associated with vascular death (Hazard ratio, 1.12; 95% CI:0.29-4.36, p=0.869). Hazard ratios for recurrent ICH were 2.24(95% CI:0.56-8.88, p=0.255) for antiplatelet exposure, and 0.32(95% CI:0.08-1.26, p=0.105) for index AICH at a deep hemispheric location. CONCLUSION: Antiplatelet resumption after AICH was not associated with an increased risk of vascular death. In view of the high rate of ischemic vascular event among survivors of AICH, antiplatelet resumption should be considered, especially in survivors with lower risk of recurrent ICH.