Quick Take: Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART)

Patients with a history of occlusive vascular disease who are on antithrombotic therapy are at an increased risk of intracerebral hemorrhage. Generally, antithrombotic therapy is discontinued after intracerebral hemorrhage in these patients. However, no published randomized trials have studied the long-term safety of antithrombotic therapy in survivors of intracerebral hemorrhage. In this randomized, controlled, open-label trial, 537 patients taking antithrombotic therapy (antiplatelet or anticoagulant) for the prevention of occlusive vascular disease and who subsequently developed intracerebral hemorrhage and discontinued antithrombotic therapy were assigned to restart or avoid antiplatelet therapy. Patients were then monitored for recurrent symptomatic intracerebral hemorrhage for a median of 2.0 years (IQR 1.0 to 3.0 years). At baseline, patients were on average 76 years old, and approximately two-thirds were male. At the onset of intracerebral hemorrhage, 50% of the participants were taking aspirin, approximately 25% were taking clopidogrel, and approximately 20% were taking oral anticoagulation. Researchers found that more patients who were allocated to avoid antiplatelet therapy experienced a recurrence of intracerebral hemorrhage as compared to those who were allocated to antiplatelet therapy (9% vs. 4% respectively, HR 0.51, 95% CI 0.25 to 1.03, p=0.060); however, this difference was not statistically significant. Furthermore, there were no statistically significant differences in the rate of major bleeding events nor the rate of major occlusive vascular events between the groups. This study was limited by low recruitment, as only 537 of 720 intended participants were recruited. In summary, this study does not demonstrate a clear risk of recurrent intracerebral hemorrhage after an initial intracerebral hemorrhage in patients maintained on antiplatelet therapy for occlusive vascular disease, suggesting that the benefits of secondary prevention may outweigh the risks in these patients.

Click to read the study in Lancet

Image: PD

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