ABSTRACT NUMBER: ESOC2026A1797 ORAL ANTICOAGULANTS FOR SECONDARY PREVENTION IN ATRIAL FIBRILLATION PATIENTS WITH PRIOR INTRACRANIAL HEMORRHAGE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF TEN STUDIES

Abstract Background and aims Patients with atrial fibrillation (AF) who survive intracranial hemorrhage (ICH) face a complex therapeutic challenge. While oral anticoagulants (OACs) are effective in preventing thromboembolism in AF, their safety and efficacy in patients with a history of ICH remain uncertain. This meta-analysis aimed to evaluate the outcomes of OAC therapy compared to no antithrombotic therapy in this high-risk population. Methods We conducted a pairwise meta-analysis of studies comparing OAC to no therapy in AF patients post-ICH. Outcomes assessed included thromboembolic events, recurrent ICH, and all-cause mortality. Random-effects models were used to pool results. Results Nine studies were included, comprising three Randomized controlled trials (RCTs) and six observational cohorts. In RCTs, OACs significantly reduced the risk of stroke (HR: 0.62; 95% CI: 0.40–0.96), with a marked reduction in ischemic adverse events (HR: 0.36; 95% CI: 0.19–0.67). However, an increased risk of hemorrhagic events was noted (HR: 2.54; 95% CI: 1.02–6.35). In the observational studies, OACs were associated with a lower odds of thromboembolism (OR: 0.38; 95% CI: 0.21–0.67) and all-cause mortality (OR: 0.45; 95% CI: 0.25–0.84) compared to no therapy, without a statistically significant increase in recurrent ICH (OR: 0.86; 95% CI: 0.23–3.62). Conclusions Across both RCTs and observational studies, OACs demonstrated a consistent benefit in reducing thromboembolic events and mortality in AF patients with prior ICH, albeit at the cost of an increased bleeding risk observed in RCTs. These findings suggest that restarting OACs may be beneficial for carefully selected patients, emphasizing the need for individualized risk stratification. Conflict of interest All authors: nothing to disclose