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Patient Evidence Summary
Doctor, I have atrial fibrillation and previously had a bleed into my brain. Should I be treated with a blood thinner to protect me from stroke going forward?
In people with atrial fibrillation and a previous intracerebral hemorrhage, treatment with a DOAC reduced the risk of stroke, but increased the risk of another intracerebral hemorrhage.
The decision to take a blood thinner if you have atrial fibrillation and previously had an intracerebral hemorrhage should be personalized after discussing your specific situation with your doctor.
Study highlights
In people with atrial fibrillation and a previous intracerebral hemorrhage, around 1 out of 100 people treated with a DOAC had a stroke, compared to around 12 out of 100 people who did not take a DOAC.
In this same group, around 7 out of 100 people who took a DOAC had another intracerebral hemorrhage, compared to around 1 out of 100 people who did not take a DOAC.
Understanding the problem
People with atrial fibrillation are at higher risk of having a stroke. To reduce this risk, many of these people are treated with blood thinners known as DOACs. While DOACs are effective at preventing stroke, they can increase the risk of bleeding.
Bleeding inside the brain, or intracerebral hemorrhage, is one of the most severe types of bleeding and can lead to permanent disability or death. People who previously had an intracerebral hemorrhage are at higher risk of having another one.
Before this study, it was unknown whether people with atrial fibrillation and a prior intracerebral hemorrhage should be treated with a DOAC to reduce the risk of stroke. This study aimed to answer this question by comparing the use of a DOAC versus no anticoagulant in people with atrial fibrillation and a previous intracerebral hemorrhage.
Who? The study included 319 adults (median age 79 years, 65% male), with atrial fibrillation and an intracerebral hemorrhage in the prior 2 to 52 weeks. This study excluded people who had intracerebral hemorrhage due to trauma or a structural issue with blood vessels in the brain
What? The study compared anticoagulation with any DOAC compared to no anticoagulant.
Anticoagulation with a DOAC | vs | No Anticoagulation |
|---|---|---|
Any DOAC (apixaban, rivaroxaban, edoxaban, or dabigatran). The patient's doctor chose the DOAC, and standard dosing for atrial fibrillation was used. The DOAC was started within 2 to 52 weeks after the intracerebral hemorrhage, at the discretion of the doctor and patient. | No anticoagulation was taken. |
Anticoagulation with a DOAC vs no anticoagulation in people who have atrial fibrillation and a history of intracerebral hemorrhage.
Outcomes | Rate of events with DOAC | Rate of events with no anticoagulation | Results |
|---|---|---|---|
Stroke | About 1 out of 100 people | 12 out of 100 people | Around 11 fewer people out of 100 had a stroke while taking a DOAC compared to those who were not taking anticoagulation |
Intracerebral hemorrhage | 7 out of 100 people | About 1 out of 100 people | Around 6 more people out of 100 had another intracerebral hemorrhage while taking a DOAC compared to those who were not taking anticoagulation. |
This Evidence Summary is based on the following article:
Veltkamp R, Korompoki E, Harvey KH, et al. Direct oral anticoagulants versus no anticoagulation for the prevention of stroke in survivors of intracerebral haemorrhage with atrial fibrillation (PRESTIGE-AF): a multicentre, open-label, randomised, phase 3 trial. Lancet. 2025 Mar 15;405(10482):927-936. doi: 10.1016/S0140-6736(25)00333-2. Epub 2025 Feb 26. PubMed
Ali Eshaghpour, MD
Ali Eshaghpour is a PGY4 Hematology resident at McMaster University, where he previously completed his medical school and Internal Medicine training. Ali has clinical and research interests in thrombosis medicine, and hopes to pursue further training in health research methodology after his residency.
Siraj Mithoowani, MD, MHPE, FRCPC, FACP
Siraj Mithoowani is an Assistant Professor in the Department of Medicine, McMaster University, and is a clinical hematologist at St. Joseph's Healthcare, Hamilton. He specializes in the care of non-malignant and thrombotic blood disorders. His research interests are in venous thromboembolism and postgraduate medical education.
Published: Tuesday, May 6, 2025
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
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This Evidence Summary was printed from the CLOT+ website on 2025/09/18. To view other Evidence Summaries or to register to receive email notifications about new Evidence Summaries, please visit us at https://plus.mcmaster.ca/ClotPlus/Articles/EvidenceSummaries |
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, McMaster University