Antiplatelet Therapy After Spontaneous Intracerebral Hemorrhage and Functional Outcomes

Santosh B. Murthy, MD, MPH; Alessandro Biffi, MD; Guido J. Falcone, MD, ScD, MPH; Lauren H. Sansing, MD, MS; Victor Torres Lopez, BS; Babak B. Navi, MD, MS; David J. Roh, MD; Pitchaiah Mandava, MD, PhD, MSEE; Daniel F. Hanley, MD; Wendy C. Ziai, MD, MPH; Hooman Kamel, MD; Jonathan Rosand, MD; Kevin N. Sheth, MD

Disclosures

Stroke. 2019;50(11):3057-3063. 

In This Article

Results

We included a total of 2801 ICH patients, of whom 288 (10.3%) were started on APT after ICH. Demographics, comorbidities, and ICH characteristics of the 3 cohorts are shown in Table 1. There were no major significant differences in baseline demographics, hematoma characteristics, or clinical severity between the 2 groups. The median times from ICH diagnosis to use of APT were 11 days (interquartile range, [IQR], 7–15), 39 days (IQR, 11–66), and 7 days (IQR, 5–15), in the MGH, VISTA-ICH, and Yale cohorts, respectively. Among patients on APT after ICH, prior APT was reported in 73 (32.9%, MGH), 10 (23.8%, VISTA-ICH), and 1 (4.2%, Yale) patients (Table 2).

In the multivariable Cox models, we adjusted for age, sex, admission Glasgow Coma Scale score, admission hematoma volumes, presence of intraventricular hemorrhage, and prior APT. APT after ICH was not associated with mortality or the composite of death or major disability in any of the cohorts (Figure 1). In the meta-analysis of the 3 cohorts, APT after ICH was not associated with mortality compared with patients not started on APT (pooled HR, 0.85; 95% CI, 0.66–1.09; Figure 1). There was no evidence of heterogeneity (I2 =0, P for Cochran Q=0.61). Similarly, APT was not associated with death or major disability compared with patients not on APT (pooled HR, 0.83; 95% CI, 0.59–1.16). There was no evidence of heterogeneity (I2 =0; P for Cochran Q=0.43).

Figure 1.

Forest plot of the association between antiplatelet therapy and mortality (top) and disability (bottom) after intracerebral hemorrhage. The meta-analysis was calculated using a random-effects model, with the pooled relative risk shown in the forest plot. Each square represents the point estimate of any given study's effect size. The size of the squares is proportional to the inverse of the variance of the estimate, while the horizontal lines represent each study's 95% CIs. The diamond represents the pooled estimate with the width of the diamond representing the pooled 95% CI. ICH indicates intracerebral hemorrhage; MGH, Massachusetts General Hospital; mRS, modified Rankin Scale; and VISTA-ICH, Virtual International Stroke Trials Archive-ICH.

When stratified by hematoma location, APT use after ICH was not associated with mortality (HR, 0.85; 95% CI, 0.55–1.32) or mRS score 4 to 6 (HR, 0.91; 95% CI, 0.64–1.31) in lobar ICH (Figure 2). Similarly, there was no association between APT and mortality (HR, 0.88; 95% CI, 0.65–1.20) or mRS score 4 to 6 (HR, 0.89; 95% CI, 0.52–1.55) in deep ICH (Figure 3). We only included HRs from the MGH and VISTA-ICH cohorts for this analysis because the Yale cohort lacked power to calculate a HR for lobar and deep ICH.

Figure 2.

Forest plot of the association between antiplatelet therapy and mortality (top) and disability (bottom) in lobar intracerebral hemorrhage. ICH indicates intracerebral hemorrhage; MGH, Massachusetts General Hospital; mRS, modified Rankin Scale; and VISTA-ICH, Virtual International Stroke Trials Archive-ICH.

Figure 3.

Forest plot of the association between antiplatelet therapy and mortality (top) and disability (bottom) in deep intracerebral hemorrhage. ICH indicates intracerebral hemorrhage; MGH, Massachusetts General Hospital; mRS, modified Rankin Scale; and VISTA-ICH, Virtual International Stroke Trials Archive-ICH.

In post hoc analyses, we studied ICH outcomes based on whether APT was resumed or started de novo. De novo starting of APT was not associated with ICH outcomes compared with patients not on APT (Figures I and II in the online-only Data Supplement). Similarly, APT resumption did not influence mortality or functional outcome compared with patients not on APT (Figures III and IV in the online-only Data Supplement). Furthermore, comparison of patients restarted on APT with those in whom APT was started de novo showed similar odds of outcome (Table I in the online-only Data Supplement).

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