From the Guidelines
Bridging with aspirin is not recommended for patients with hemorrhagic stroke and atrial fibrillation (AFib) as it may increase the risk of rebleeding. The management of patients with hemorrhagic stroke and AFib requires careful consideration of the risks and benefits of anticoagulation therapy. According to the American College of Chest Physicians evidence-based clinical practice guidelines 1, patients with a history of ischemic stroke or TIA and atrial fibrillation who are unsuitable for or choose not to take an oral anticoagulant may be treated with combination therapy with aspirin and clopidogrel. However, this guideline does not specifically address the management of patients with hemorrhagic stroke.
In clinical practice, after a hemorrhagic stroke, anticoagulation therapy (including aspirin) is typically withheld for at least 4-8 weeks to allow the brain to heal and reduce the risk of rebleeding. When anticoagulation is eventually restarted in AFib patients, direct oral anticoagulants (DOACs) like apixaban or warfarin are usually preferred over aspirin, as they provide superior stroke prevention benefits in AFib. The decision to restart anticoagulation should be individualized based on the patient's specific bleeding risk factors, stroke risk (CHA₂DS₂-VASc score), and the characteristics of the hemorrhage. Factors that might influence timing include hematoma size, location, stability on imaging, blood pressure control, and whether the underlying cause of bleeding has been addressed.
Some key points to consider in the management of these patients include:
- The risk of recurrent hemorrhage versus the risk of ischemic stroke from untreated AFib
- The use of alternative therapies such as left atrial appendage closure in patients with very high bleeding risk
- The importance of individualizing treatment decisions based on patient-specific factors
- The need to carefully monitor patients for signs of rebleeding or ischemic stroke after anticoagulation is restarted.
From the Research
Role of Bridging with Aspirin in Patients with Hemorrhagic Stroke and Atrial Fibrillation
- The use of aspirin in combination with anticoagulant therapy in patients with atrial fibrillation (AF) has been explored in several studies 2, 3, 4, 5, 6.
- A study published in 2013 found that bridging therapy with warfarin appeared to be safe and was not associated with an increase in adverse events in patients with ischemic stroke and AF 2.
- However, another study published in 2024 highlighted the complex management dilemma of anticoagulation in elderly patients with AF and recurrent strokes, emphasizing the need for a multidisciplinary approach and individualized decision-making 3.
- The combination of aspirin with anticoagulant therapy has been shown to be associated with an increased risk of major bleeding, particularly when combined with warfarin 4.
- A study published in 2020 found that anticoagulation with directly acting anticoagulants would result in no clinically significant gain or loss in 73% of patients with intracerebral hemorrhage (ICH) and AF, while 12% would gain >0.1 quality-adjusted life years (QALYs) and 15% would lose >0.1 QALYs 5.
- Another study published in 2018 found that hemorrhagic transformation (HT) was associated with increased mortality or disability in patients with acute ischemic stroke and AF, and that anticoagulation was initiated about 12 days later in patients with HT compared to those without HT 6.
Key Findings
- Bridging therapy with warfarin may be safe in patients with ischemic stroke and AF 2.
- The combination of aspirin with anticoagulant therapy is associated with an increased risk of major bleeding 4.
- Anticoagulation with directly acting anticoagulants may not result in a clinically significant gain or loss in most patients with ICH and AF 5.
- HT is associated with increased mortality or disability in patients with acute ischemic stroke and AF 6.