Abstract
Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF pts with intracerebral hemorrhage (ICH) are at increased risk of bleeding with anticoagulation (AC). Optimal decision-making must weigh the tradeoffs between these competing risks. Our goal was to analyze the impact of AC decisions on projected quality-adjusted life years (QALYs) pts with both ICH and AF within a population. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study is a population-based evaluation of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky study region. The study period was 7/08-12/12. Pts with ICH and AF surviving the hospital stay were included. Medical history and demographics were entered into the Atrial Fibrillation Decision Support Tool, which is a 29-state Markov decision analytic model that projects patient-level QALYs for 7 thromboprophylaxis treatment strategies, using published event rates from CHADSVASC, HAS-B(L)ED, the Friberg ICH prediction model and clinical trials of anticoagulants (including warfarin and direct anticoagulants, DOACs), as well as published rates of outcomes for each possible event. Results: In the study period, there were 1186 cases of spontaneous ICH, 232 with a-fib, of which 123 were excluded because of inpatient death/discharge to hospice. Among the 109 cases, the aggregate net loss for AC was 16.9 QALYs; however there were 10 cases (9%) that gained > 0.1 QALYs with AC. The table displays a heat map showing aggregate gain/loss of QALYs with AC (compared with no treatment) for the cohort, displayed by their CHADSVASC and HASBED scores. Conclusion: We found that 91% of our ICH pts with AF would have either no change or a loss of QALYs with AC. However, given lower bleeding rates with DOACs, anticoagulation may be beneficial in a very select subset of AF pts with ICH. Thresholds for AC treatment should be considered carefully in this population.
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