Newer anticoagulants may help prevent strokes in AFib patients with previous brain bleeds

by American Academy of Neurology

edited by Sadie Harley, reviewed by Robert Egan

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For people with atrial fibrillation (AFib), an irregular heartbeat, and intracranial hemorrhage, a type of stroke also known as a brain bleed, anticoagulant use was associated with a lower risk of ischemic stroke and death, according to a new study published in Neurology. The study also found no increased risk of more brain bleeds when people took newer anticoagulants.

Anticoagulants are drugs that stop the blood from clotting easily. Ischemic stroke is when blood flow is blocked, often by a blood clot, to part of the brain.

While newer anticoagulants were not associated with an increased risk of future brain bleeds, warfarin, an older anticoagulant, was. Newer anticoagulants, called direct oral anticoagulants, include apixaban, rivaroxaban, edoxaban and dabigatran.

Because this was an observational study, the findings do not show that anticoagulants caused these differences in risk, only that they were associated with them.

"Anticoagulants can help prevent ischemic stroke, but for people with atrial fibrillation who have had a previous brain bleed, treatment decisions can be complex due to concern about the possibility of another brain bleed," said Paula Tiili, M.D., of the University of Helsinki in Finland.

"For our study, we wanted to better understand the risks of ischemic stroke and brain bleeds in people using newer and older anticoagulants."

Tracking outcomes after a prior brain bleed

The study included 1,502 people with an average age of 78 who had AFib and brain bleeds that occurred at least four months prior to their AFib diagnosis. They were followed for up to two years. Of the participants, 15% received newer anticoagulants, 29% received warfarin and 56% received no anticoagulants.

During the study, 57 had an ischemic stroke, 45 people had new brain bleeds and 257 died.

Newer anticoagulants linked to lower stroke risk

After adjusting for factors such as age, high cholesterol and high blood pressure, researchers found that at one year after an AFib diagnosis, fewer than 1% of people taking newer anticoagulants had an ischemic stroke compared to 2% of those taking warfarin and 4% of those taking no anticoagulants.

Researchers found that 1% of people taking newer anticoagulants had a new brain bleed compared to 3% of people taking warfarin and 2% of people taking no anticoagulants.

They also found that 5% of people taking newer anticoagulants died of causes other than stroke within that first year, compared to 9% of people taking warfarin and 15% taking no anticoagulants.

Compared with taking no medications, newer anticoagulant use was associated with an 83% lower risk of ischemic stroke and an 80% lower risk of death, without an increased risk of intracranial bleeding.

Warfarin use was associated with a 51% lower risk of ischemic stroke and 40% lower risk of death, but an 85% higher risk of brain bleeds.

Individual treatment decisions still require caution

"Our study found that anticoagulant use was linked to a lower risk of ischemic stroke and death in this high-risk group," said Tiili. "Importantly, our study found newer anticoagulants were not associated with another brain bleed, while warfarin was.

"Our findings may help clinicians make more individualized treatment decisions when trying to prevent stroke in people with AFib and prior brain bleeds. However, more research is needed to identify who is most likely to benefit and who may still face a higher bleeding risk."

A limitation of the study was that researchers included only people who did not have a stroke or die within the first three months after an AFib diagnosis, so the results may not apply to people in that earlier period of time.

Publication details

Neurology (2026)

Journal information: Neurology

Key medical concepts

Atrial FibrillationIntracranial HemorrhagesIschemic StrokeDirect Oral AnticoagulantWarfarin

Clinical categories

NeurologyCardiologyClinical pharmacology Provided by American Academy of Neurology Who's behind this story?

Sadie Harley

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Robert Egan

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