Abstract WP142: Comparison of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Recent Intracerebral Hemorrhage

Background: The optimal anticoagulation strategy for patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) remains uncertain. Although direct oral anticoagulants (DOACs) have largely replaced warfarin as first-line therapy for stroke prevention in AF—due to their lower risk of intracranial bleeding and fewer drug–food interactions—their safety and efficacy in patients with both AF and recent ICH remain poorly defined. This study aimed to compare the rates of ischemic and hemorrhagic stroke between patients receiving DOACs versus warfarin following an ICH. Methods: We conducted a retrospective cohort study using the COSMOS EPIC database, identifying adult patients admitted with ICH and have AF diagnosis. Patients were included if they had a documented anticoagulation prescription within 180 days of discharge after the index ICH admission. Diagnoses were identified using ICD-10 codes. Patients were stratified into two groups based on anticoagulant type: DOAC or warfarin. Baseline demographic and clinical characteristics, including comorbidities, were compared. The primary outcomes were recurrent hemorrhagic stroke (ICH or subarachnoid hemorrhage) and ischemic stroke after anticoagulation initiation. Kaplan–Meier survival curves were generated to estimate the cumulative incidence of each outcome, and differences were assessed using log-rank tests. Results: A total of 2,473 patients met inclusion criteria. Patients in the DOAC group were slightly older than those in the warfarin group (mean age 73 vs. 71 years, p = 0.02); other baseline characteristics and comorbidities were comparable. During follow-up, ischemic stroke occurred in 3.5% of DOAC-treated patients and 3.1% of warfarin-treated patients ( p = 0.70). Hemorrhagic stroke occurred in 7.4% and 6.1% of patients in the DOAC and warfarin groups, respectively ( p = 0.68). Kaplan–Meier analysis demonstrated no significant difference in the cumulative incidence of hemorrhagic stroke ( p = 0.60) or ischemic stroke ( p = 0.80) between groups. Conclusion: In this large retrospective cohort of patients with AF and ICH, DOAC and warfarin had comparable risk of recurrent hemorrhagic or ischemic strokes. Prospective studies are needed to guide anticoagulation decisions in this high-risk group.