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January 9, 2007 — A new study suggests that the rate of intracerebral hemorrhage (ICH) associated with the use of anticoagulants increased five-fold during the 1990s and up to 10-fold in the elderly.

Most of the increase, the researchers say, is explained by the growing use of warfarin in patients with atrial fibrillation (AF), after a number of studies during that decade confirmed that treatment reduced stroke in this population. These findings of an accompanying increase in ICH, a known risk with warfarin therapy, do not mean that the benefits may not still outweigh the risks for many people, they say.

"Our findings should not discourage the use of warfarin when it's appropriate," lead author Matthew L. Flaherty, MD, from the University of Cincinnati Medical Center, in Ohio, said in a press release from the American Academy of Neurology. "Doctors can use these findings to make sure they are weighing the risks and benefits of warfarin use for their patients. For researchers, these results may stimulate efforts to develop safer alternatives to warfarin and better treatments for people with brain hemorrhages."

The report is published in the January 9 issue of Neurology.

Growing Warfarin Use

Warfarin use has increased since publication during the 1990s of such landmark studies as the Stroke Prevention in Atrial Fibrillation (SPAF) trials, among others, showing that anticoagulation with warfarin could significantly reduce the risk for stroke in patients with AF. The risk/benefit ratio for warfarin treatment is good when patients are at high risk for stroke but "narrower" when used in primary prevention in the elderly, where the benefit may be offset by bleeding risk, they write.

Although ICH is the "most-feared" complication of treatment, precise estimates of anticoagulant-associated ICH are not available, they note. In this study, Dr. Flaherty and colleagues identified all patients in the Greater Cincinnati/Northern Kentucky area who were hospitalized with first-ever ICH during 3 periods: 1988, 1993–94, and 1999 — that is, before and after the major anticoagulant trials in AF. The hemorrhages were considered anticoagulant-associated if the patient was on warfarin or heparin.

They found the annualized rate of anticoagulant-associated ICH (AAICH) increased significantly over the 3 periods, as did the percentage of overall ICH cases that it represented.

Anticoagulation Associated Intracerebral Hemorrhage Rates 1998–1999