ICH in NOAC vs Warfarin and Mortality

Written by Alex Chen, MD

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Among patients with ICH, those on non-vitamin K oral anticoagulants (NOACs) had a lower in-hospital risk of mortality compared to warfarin (26.5% vs 32.6%). Compared to warfarin, those on NOACs were more likely to be discharged home (+3.3%), be functionally independent (+2.5%), and have the ability to ambulate independently at discharge (+1.8%).

Why does this matter?
One of the main concerns with anticoagulation is the risk of intracerebral hemorrhage. There is concern that, unlike warfarin, some of the NOACs can't be reversed.  Prior studies have suggested that the NOACs have a more favorable safety profile compared to warfarin.  This study took a look at an important, patient-centered outcome (mortality) and had a larger scope and size.

This is your brain on warfarin.
This was a retrospective cohort study that evaluated 141,311 patients from Oct 2013 to Dec 2016 with ICH from 1662 hospitals across the US. They stratified patients based on whether or not they took NOACs, warfarin, or no anticoagulants. They also looked at concomitant anti-platelet use.  Using non-anticoagulated patients as a reference, in-hospital mortality was higher in both the NOAC (+3.3%) and warfarin (+9%) groups. If you were on warfarin, you were also less likely to be discharged home (-3%) or be functionally independent (-3.1%). When comparing NOACs to warfarin, there was decreased in-hospital mortality for those on NOACs (-5.7%, adjusted).  Addition of dual anti-platelet agents to anticoagulants was associated with increased in-hospital mortality, with a trend toward lower mortality in those on NOACs vs warfarin, but this was not statistically significant. Bottom line is if you had to have a head bleed on an anti-coagulant, it would be better if you were on a NOAC vs warfarin.

Association of Intracerebral Hemorrhage Among Patients Taking Non-Vitamin K Antagonist vs Vitamin K Antagonist Oral Anticoagulants With In-Hospital Mortality.  JAMA. 2018 Feb 6;319(5):463-473. doi: 10.1001/jama.2017.21917.

Reviewed by Clay Smith.

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