Background: Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (a-fib) are at risk for having future ischemic events after stopping anticoagulation. Risk calculators (CHA2DS2-VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and for major bleeding in a-fib patients. We sought to compare the distribution of these scores among ICH patients with a-fib within a large biracial population.
Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study included a population-based retrospective chart review of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between 7/2008 and 12/2012. CHA2DS2-VASc (risk of ischemic stroke) and HAS-BED (risk of bleeding with anticoagulation; minus “L” because “labile INR” was unavailable) scores were calculated for all ICH patients with a-fib who survived the hospital stay. Published risk coefficients for each score were used to calculate predicted ischemic and bleeding events within one year of onset.
Results: Among 1186 cases of spontaneous ICH, 232 had a-fib, of which 123 patients were excluded due to inpatient death or discharge to hospice. Among the remaining 109 cases, 7-8 would be expected to have a major bleeding event (on anticoagulation), and about 6 patients would be expected to have an ischemic stroke within one year (off anticoagulation), with 73 of the 109 patients having higher risk for major bleeding than for ischemic stroke. The correlation between the two scores was weak (Spearman r=.220, p=.021).
Discussion: Comparison of CHA2DS2-VASc and HAS-BED scores suggest a higher CHA2DS2-VASc threshold for considering anticoagulation is needed for ICH a-fib patients to balance their higher risk of major bleeding. Further evaluation of the consequences of ischemic stroke and major bleeding would be needed to better understand the best treatment strategies for our patients.