No rise in major hemorrhagic events with antiplatelet therapy after ICH


Background: Antiplatelet agents reduce the risk of major vascular events in patient with established vaso-occlusive disease, but they may increase the risk of ICH. Patients with prior ICH are at risk for both vaso-occlusive and hemorrhagic events. Clarification of the relative risk and benefit of antiplatelet agent use in this clinical scenario would serve to guide therapy.

Dr. Steven Deitelzweig

Study design: Prospective, open-label, randomized parallel group trial.

Setting: 122 hospitals located in the United Kingdom.

Synopsis: The study included 537 adult patients with imaging-confirmed, nontraumatic intracerebral hemorrhage who were previously prescribed antithrombotic medications were randomized in 1:1 fashion to either start or avoid antiplatelet therapy. Participants were followed up on an annual basis with postal questionnaires both to the participants and their primary care providers. No significant difference was identified in rates of recurrent ICH (adjusted hazard ratio, 0.51; 95% confidence interval, 0.25-1.03), major hemorrhagic events (aHR, 0.71; 95% CI, 0.39-1.30), or major occlusive vascular events (aHR, 1.02; 95% CI, 0.65-1.60) between groups.

Hospitalists should be aware that these data suggest that the risk assessment for resumption of antiplatelet agents should not be affected by a history of nontraumatic intracerebral hemorrhage when weighed against the benefit of these medications in patients with occlusive vascular disease.

Bottom line: Resumption of antiplatelet agents following intracerebral hemorrhage showed no evidence of increased risk of recurrent intracerebral hemorrhage or major hemorrhagic events.

Citation: RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): A randomized, open-label trial. Lancet. 2019. doi: 10.1016/S0140-6736(19)30840-2.

Dr. Deitelzweig is system department chair of hospital medicine at Ochsner Health System, New Orleans.

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