Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Prior Use of NOACs & Mortality in ICH Patients

JAMA; 2018 Feb 6; Inohara, Xian, Liang, et al

Among patients with intracerebral hemorrhage (ICH), prior use of non-vitamin K antagonist oral anticoagulants (NOACs), compared with prior warfarin use, was associated with a lower risk of in-hospital mortality, a recent study found. The retrospective cohort study included 141,311 patients (mean age 68.3 years, 48% women) with ICH admitted from October 2013 to December 2016. Among the findings:

  • 15,036 patients were taking warfarin and 4,918 were taking NOACs preceding ICH, and 39,585 and 5,783 patients were taking concomitant single and dual antiplatelet agents, respectively.
  • Acute ICH stroke severity was not significantly different across the 3 groups.
  • The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs.
  • Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference [ARD], 9.0%; adjusted odds ratio, 1.62) and higher among patients with prior use of NOACs (ARD, 3.3%; AOR, 1.21).
  • Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, ‒5.7%; AOR, 0.75).


Inohara T, Xian Y, Liang L, et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA.2018;319(5):463–473. doi:10.1001/jama.2017.21917.


Randomized clinical trials have shown that NOACs have a lower rate of ICH than warfarin.1,2 The concern until now has been, given the lack until recently of a reversal agent for the NOACs, what are the outcomes of the ICHs that occur on NOACs compared to the ICHs that occur on warfarin. This study shows that patients with prior use of NOACs compared with those with prior use of warfarin were more likely to have favorable outcomes with less mortality and disability. Given that NOACs have a lower rate of ICHs and those ICHs that occur have a better outcome, NOACs continue to be more and more attractive for treatment of atrial fibrillation and venous thromboembolic disease. —Neil Skolnik, MD

  1. Hart RG, Diener HC, Yang S, et al. Intracranial hemorrhage in atrial fibrillation patients during anticoagulation with warfarin or dabigatran: the RE-LY trial. Stroke. 2012;43(6):1511-1517.
  2. Hankey GJ, Stevens SR, Piccini JP, et al; ROCKET AF Steering Committee and Investigators. Intracranial hemorrhage among patients with atrial fibrillation anticoagulated with warfarin or rivaroxaban: the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation. Stroke. 2014;45(5):1304-1312.