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OAC Restart After ICH — EECC MCQ

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HardArrhythmia & ElectrophysiologyOAC Restart After ICHEECC

A 55-year-old man with AF and a CHA₂DS₂-VA score of 3 on apixaban falls and sustains a traumatic intracranial haemorrhage. Apixaban is stopped. After neurosurgical management, he recovers well. When should anticoagulation be restarted?

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Correct answer: A — Restart anticoagulation after 4-8 weeks, following multidisciplinary discussion between cardiology, neurology/neurosurgery, and the patient

Restarting anticoagulation after intracranial haemorrhage (ICH) is a complex risk-benefit decision. Observational studies suggest that restarting OAC after ICH (typically at 4-8 weeks) is associated with reduced ischaemic stroke and mortality without a significant increase in recurrent ICH. The 2024 ESC AF Guidelines recommend a multidisciplinary approach (cardiology, neurology/neurosurgery) to determine optimal timing, considering: location of ICH (lobar vs deep), presence of modifiable risk factors (hypertension, amyloid angiopathy), stroke risk (CHA₂DS₂-VA), and patient preferences. DOACs are preferred over warfarin for restart due to their lower ICH risk. LAA occlusion may be considered as an alternative.

Reference: ESC (2024): Guidelines for the Management of Atrial Fibrillation