Oral anticoagulation after intracranial haemorrhage: A survey of UK stroke physicians

Abstract

Introduction: Observational studies suggest that starting oral anticoagulation (OAC) after intracranial haemorrhage (ICH) is beneficial, but a randomised controlled trial (RCT) is needed to confirm this. We assessed opinion about this treatment uncertainty amongst stroke physicians in the UK. Method: In May 2015, we used Survey Monkey to email an online questionnaire to 289 doctors on the delegation logs at 111 hospital sites participating in the REstart or STop Antithrombotics Randomised Trial (www.RESTARTtrial.org; ISRCTN71907627), followed by 3 email reminders to non-responders. Results: Of 289 invitees, one had opted out of Survey Monkey, 17 emails bounced, 109 (38%) did not respond, and 15 partially completed the survey, leaving 147 (51%) complete responses. 95% of respondents were uncertain whether to start OAC in at least some patients with indications for OAC after ICH. Physicians would randomise patients with atrial fibrillation (AF) and a CHA2DS2-VASc score >1 (88%), recurrent venous thromboembolism (78%) or other cardiac indications (80%). One quarter of respondents would prefer to use adjusted dose warfarin and the rest would use a new OAC (of whom 50% would use apixaban and 29% would use any new OAC). In a RCT the preferred comparator was avoidance of all antithrombotic drugs for patients with lone AF (73%) and an antiplatelet drug for patients with a past history of vaso-occlusive disease (89%). 82% of respondents were just as, or more, keen to participate in RESTART-OAC than RESTART-antiplatelets. Discussion: Equipoise about starting OAC after ICH and physicians' keenness to participate support the need for RESTART-OAC.