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Anticoagulants Increase Risk of Hemorrhagic-Type Strokes
Background: Of late we’ve written a lot about A-Fib stroke and the risk of Ischemic stroke which occurs when a clot blocks a blood vessel to the brain.
While ischemic stroke is the most common kind of stroke among A-Fib patients, there is another type of stroke threat, an Intracerebral Hemorrhagic stroke. An ICH stroke is caused by a leaked or ruptured blood vessel in the brain. Although less common in A-Fib patients, an ICH stroke can be just as or even more devastating, even deadly.
Anticoagulants and Intracerebral Hemorrhage Stroke (ICH)
For A-Fib patients, anticoagulants are used for the prevention of clots and stroke. But according to Dr. M. Edip Gurol, anticoagulants may actually increase the risk of Intracerebral Hemorrhagic (ICH) stroke. (Bleeding events are common complications of direct oral anticoagulants [DOACs].)
While Intracerebral Hemorrhagic (ICH) stroke is less common than Ischemic stroke, it is a more deadly and disabling type of stroke. Although accounting for only 15 percent of all strokes, hemorrhagic strokes are responsible for about 40 percent of all stroke deaths.
Added June 15, 2022: “About one-quarter of older adults (over 65) on an anticoagulant who develop a brain bleed will die as a result, versus 9% of elderly patients who are not on anticoagulant therapy.” (Bottom Line Personal, Volume 43, Number 11, June 1, 2022. p. 8.)
Dr, M. Edip Gurol
Dr. M. Edip Gurol’s comments are published in the March 18, 2018 issue Cardiac Rhythm News. A stroke neurologist specialist at Mass. General Hospital, he has a particular expertise in the care of patients at high risk for ischemic (blockage type) strokes and hemorrhages.
According to Dr. Gurol, over 50% of patients sustaining a warfarin-related intracerebral hemorrhagic [ICH] stroke die within the first three months.
Are the outcomes any better for patients on the newer NOACs (New Oral Anticoagulants) who have an ICH? No, the outcomes are just as dismal, similar to patients having a warfarin-related ICH stroke.
The Link With Cerebral Microbleeds (CMBs)
Growing evidence suggests a link between cerebral microbleeds (small chronic brain hemorrhages of the small vessels of the brain) and increased risk of intracerebral hemorrhage stroke (ICH).
This has led to concerns about the safety of administering anticoaglulant drugs in patients with cerebral microbleeds (CMBs).
About cerebral microbleeds, Dr. Gurol warns:
“The presence of one or more CMBs [cerebral microbleeds] conferred a five to six times higher ICH (hemorrhagic stroke) risk,”
“OACs [anticoagulants] are not benign medications in patients with CMBs even without a history of brain bleed.”
LEFT: Brain MRIs of two microbleeds in the same older adult with A-Fib taking an NOAC (red arrows point to tiny microbleed dots). RIGHT: Two years later, the patient had a hemorrhagic stroke and died. The right MRI shows the fatal hemorrhage.
How Common are Cerebral Microbleeds?
Long-term research studies using Magnetic Resonance Imaging (MRIs), show cerebral microbleeds are already present at middle age, and their prevalence rises strongly with increasing age. Microbleeds rarely disappear.
One recent MRI study found evidence of microbleeds in 99% of subjects aged 65 or older, and that increasing the imaging strength increased the number of detectable microbleeds.
Are You at Risk?
Should A-Fib patients over age 65 be taking anticoagulants for the rest of their lives? According to Dr. Gurol and his research, probably not.
In the decades-long population-based Rotterdam Study, the risk of intracerebral hemorrhage stroke was found to increase as the number of microbleeds increased.
Since almost everyone over age 65 has microbleeds, it’s all too easy for long-term anticoagulants to expand those microbleeds into full blown Intracerebral hemorrhagic strokes (ICHs).
Are There Alternatives to a Lifetime on Anticoagulants?
Yes, there are alternatives to having to take anticoagulants for the rest of your life. Read my articles: Watchman Better Than Warfarin and Are Anticoagulants Risky if Over Age 65?
Or…get your A-Fib cured so you don’t need to take an anticoagulant at all.
