NOACs superior to warfarin for outcomes after intracerebral hemorrhage

Compared to patients who used warfarin prior to experiencing intracerebral hemorrhage, those who took non-vitamin K oral anticoagulants (NOACs) were 25 percent less likely to die in the hospital, according to a study in the Journal of the American Medical Association.

In addition, patients on NOACs were more likely to be discharged home and have better functional status at discharge than those who previously used warfarin.

NOACs are increasingly used as an alternative to warfarin for preventing blood clots in patients with atrial fibrillation. However, previous studies have failed to clarify the outcomes of intracerebral hemorrhage (ICH) among patients on NOAC therapy, according to lead author Taku Inohara, MD, PhD, and colleagues.

“With the rapid adoption of NOACs in clinical practice, there is a need to better understand the outcomes among patients who develop an ICH with prior NOAC therapy compared with those experiencing ICH either with prior warfarin therapy or among those without prior oral anticoagulation,” the authors wrote.

Inohara et al. studied 141,311 patients with ICH admitted to more than 1,600 Get With the Guidelines-Stroke hospitals. The mean age of the subjects was 68.3 and 51.9 percent were men.

Unadjusted rates of in-hospital mortality were 32.6 percent for warfarin, 26.5 percent for NOACs and 22.5 percent for no OACs. While the absence of OACs was associated with the best outcomes, the adjusted mortality difference was 5.7 percent higher for warfarin versus NOACs.

Among patients with concomitant dual antiplatelet therapy prior to ICH, NOACs were associated with a 50 percent reduction in in-hospital mortality compared to warfarin. The reduction was 23 percent for patients without prior antiplatelet therapy.

“Preceding use of NOACs was associated with a decreased risk of in-hospital mortality and better in-hospital outcomes than preceding use of warfarin, and importantly, this association was consistent when patients with prior use of NOACs were compared with patients with prior use of warfarin whose INR (international normalized ratio) levels were controlled within the therapeutic range,” Inohara and colleagues wrote. “Because many of these patients should be taking OACs for prevention of thromboembolic complications, these findings suggest that NOACs may be a better option than warfarin, considering the lower mortality risk among patients with ICH with prior use of NOACs.”

A 2016 analysis found NOACs, regardless of type, were cost-effective compared to warfarin for stroke prevention. With the finding that post-ICH outcomes also favor NOACs, there is even stronger evidence for prescribing NOACs, the authors said.

A primary limitation of the study was its lack of sample size in the group with prior use of both NOACs and antiplatelet therapies. In addition, the timing of the last dose before ICH—and the amount of each medication a patient took—wasn’t available.