Antiplatelet Pretreatment Linked to Intracranial Hemorrhage Mortality

Pretreatment with antiplatelet agents is associated with high mortality rates after intracranial hemorrhage (ICH), according to a study published in Neurology.

While treatment with antithrombotics — such as vitamin K antagonists (VKA) and antiplatelet agents — increases the risk for spontaneous ICH, antiplatelet agents are generally considered to be less dangerous than VKAs. However, data on whether antiplatelet pretreatment increases mortality after ICH are limited and conflicting.

Jaume Roquer, MD, PhD, from IMIM-Hospital del Mar in Spain, and colleagues compared 24-hour and 3-month mortality rates after ICH in patients previously receiving VKAs, antiplatelet agents, or no antithrombotic pretreatment in a prospective observational study.

A total of 529 patients with spontaneous primary ICH were included, of which 147 patients were pretreated with antiplatelet agents and 89 were pretreated with VKAs.

Rates of very-early death, defined as death occurring within 24 hours of ICH, were significantly higher in patients pretreated with VKAs (27%) and antiplatelet agents (19%) than in patients not pretreated with antithrombotics (6.5%; P <.0001).

Mortality rates at 3 months were also increased in VKA-pretreated (58.4%) and antiplatelet-pretreated patients (49.7%) compared with non-pretreated patients (31.1%; P <.0001).

ICH severity and ICH volume on the patients’ first computed tomography (CT) scan were also significantly higher with VKA and antiplatelet pretreatment than with no pretreatment.

After adjusting for confounding factors, the risk of death within 24 hours and at 3 months after ICH remained elevated in patients pretreated with antiplatelet agents (odds ratio [OR], 2.55 and 1.56) and VKAs (OR, 4.24 and 2.34).

“Both VKA and antiplatelet pretreatments increased mortality in ICH patients compared with no pretreatment, mainly due to an increase in very-early death,” Dr Roquer told Neurology Advisor. According to Dr Roquer, no significant differences in mortality were observed between the VKA-pretreated and antiplatelet-pretreated groups.

Dr Roquer also noted that safety considerations should be taken into account when planning long-term antithrombotic treatment with antiplatelet agents and VKAs.

While the study found that antiplatelet pretreatment predicted higher very-early mortality, Dr Roquer acknowledged that the reason for this finding is unclear, and unanswered questions remain regarding the pathophysiology of ICH in this population. “Could the higher rates of very-early death in these patients be the consequence of the early increase in ICH volume? Do antithrombotic pretreatments increase ICH expansion?” he asked.

Reference

Roquer J, Vivanco Hidalgo RM, Ois A, et al. Antithrombotic pretreatment increases very-early mortality in primary intracerebral hemorrhage [published online February 1, 2017]. Neurology. doi:10.1212/WNL.0000000000003659