{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T05:26:29Z","timestamp":1790659589893,"version":"4.1.0"},"reference-count":18,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T00:00:00Z","timestamp":1787270400000},"content-version":"unspecified","delay-in-days":20,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Open Heart"],"accepted":{"date-parts":[[2026,8,10]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and prior intracranial haemorrhage (ICH) remains uncertain. Although direct oral anticoagulants (DOACs) have demonstrated a more favourable safety profile than vitamin K antagonists (VKAs) in the general AF population, comparative evidence in patients with previous ICH is limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a systematic review and meta-analysis comparing DOACs and VKAs in patients with AF and prior ICH. PubMed, Scopus and ScienceDirect were searched from inception to 16 March 2026. Outcomes of interest were ischaemic stroke, recurrent ICH and all-cause mortality. Risk of bias was assessed using Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I) V.2. Pooled HRs with 95% CIs were calculated using random-effects models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Five observational studies were included. Compared with VKAs, DOACs were associated with a lower risk of recurrent ICH (5 studies, HR 0.65, 95% CI 0.53 to 0.79), ischaemic stroke (4 studies, HR 0.80, 95% CI 0.68 to 0.94) and all-cause mortality (3 studies, HR 0.64, 95% CI 0.45 to 0.89). Heterogeneity was absent for ischaemic stroke and recurrent ICH (I\u00b2=0%) but substantial for mortality (I\u00b2=89%). The recurrent ICH finding remained robust across leave-one-out, Hartung-Knapp-Sidik-Jonkman and overlap-adjusted sensitivity analyses, whereas the ischaemic stroke and mortality estimates lost statistical significance under more conservative methods.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>DOACs appeared favourable over VKAs for recurrent ICH, ischaemic stroke and mortality, but certainty of evidence ranged from moderate to very low. These findings are hypothesis-generating and should inform shared decision-making, not definitive practice change, pending randomised evidence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>PROSPERO registration number<\/jats:title>\n                    <jats:p>CRD420261333839.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/openhrt-2026-004264","type":"journal-article","created":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T12:46:14Z","timestamp":1787316374000},"page":"e004264","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Walking a tightrope: the safety and efficacy of oral anticoagulants in atrial fibrillation patients with prior intracranial haemorrhage: a systematic review and meta-analysis"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-0560-5732","authenticated-orcid":false,"given":"Andreas Mercyan","family":"Anggitama","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-5322-7487","authenticated-orcid":false,"given":"Edwin Pranata","family":"Laban","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"},{"name":"Department of Neurology, Rumah Sakit Bethesda, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-5921-5561","authenticated-orcid":false,"given":"Christien Carla","family":"Bambuta","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0648-7265","authenticated-orcid":false,"given":"Christian Stefanny","family":"Gerungan","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-0423-7423","authenticated-orcid":false,"given":"Arya Taksya","family":"Bagaskara","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9328-6690","authenticated-orcid":false,"given":"Kristin Purnama","family":"Dewi","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"},{"name":"Department of Pulmonology and Respiratory Medicine, Rumah Sakit Bethesda, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1602-3384","authenticated-orcid":false,"given":"Ivana Purnama","family":"Dewi","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Kristen Duta Wacana Fakultas Kedokteran, Yogyakarta, Indonesia"},{"name":"Department of Cardiology and Vascular Medicine, Rumah Sakit Bethesda, Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"2026091603502396000_13.2.e004264.1","doi-asserted-by":"crossref","first-page":"2836","DOI":"10.1016\/j.hrthm.2025.06.023","article-title":"Effect of oral anticoagulant therapy on adverse outcomes in patients with atrial fibrillation after intracranial hemorrhage","volume":"22","author":"Kaisaier","year":"2025","journal-title":"Heart Rhythm"},{"key":"2026091603502396000_13.2.e004264.2","doi-asserted-by":"crossref","DOI":"10.3389\/fneur.2025.1667855","article-title":"Atrial fibrillation is associated with increased in-hospital mortality and complications after IV t-PA in acute ischemic stroke: evidence from the China Stroke Center Alliance (CSCA)","volume":"16","author":"Xie","year":"2025","journal-title":"Front Neurol"},{"key":"2026091603502396000_13.2.e004264.3","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1001\/jamainternmed.2016.9369","article-title":"Outcomes Associated With Resuming Warfarin Treatment After Hemorrhagic Stroke or Traumatic Intracranial Hemorrhage in Patients With Atrial Fibrillation","volume":"177","author":"Nielsen","year":"2017","journal-title":"JAMA Intern 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Hemost"},{"key":"2026091603502396000_13.2.e004264.7","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp-2025-336169"},{"key":"2026091603502396000_13.2.e004264.8","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.123.029979","article-title":"Comparing Efficacy and Safety Between Patients With Atrial Fibrillation Taking Direct Oral Anticoagulants or Warfarin After Direct Oral Anticoagulant Failure","volume":"12","author":"Hsieh","year":"2023","journal-title":"J Am Heart Assoc"},{"key":"2026091603502396000_13.2.e004264.9","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1017\/rsm.2025.10048","article-title":"The application of ROBINS-I guidance in systematic reviews of non-randomised studies: A descriptive study","volume":"17","author":"Iheozor-Ejiofor","year":"2026","journal-title":"Res Synth Methods"},{"key":"2026091603502396000_13.2.e004264.10","doi-asserted-by":"crossref","first-page":"922","DOI":"10.1017\/rsm.2025.10022","article-title":"Novel approaches for random-effects 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Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation With a History of Intracranial Hemorrhage","volume":"3","author":"Tsai","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2026091603502396000_13.2.e004264.14","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.121.022849","article-title":"Post-Intracranial Hemorrhage Antithrombotic Therapy in Patients With Atrial Fibrillation","volume":"11","author":"Lin","year":"2022","journal-title":"J Am Heart Assoc"},{"key":"2026091603502396000_13.2.e004264.15","doi-asserted-by":"crossref","first-page":"939","DOI":"10.1161\/STROKEAHA.118.023797","article-title":"Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Atrial Fibrillation Patients With Intracerebral Hemorrhage","volume":"50","author":"Nielsen","year":"2019","journal-title":"Stroke"},{"key":"2026091603502396000_13.2.e004264.16","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e318074ce79"},{"key":"2026091603502396000_13.2.e004264.17","unstructured":"Dean L . Warfarin therapy and VKORC1 and CYP genotype. In: Medical genetics summaries. National Center for Biotechnology Information (US), 2012. Available: https:\/\/www.ncbi.nlm.nih.gov\/books\/"},{"key":"2026091603502396000_13.2.e004264.18","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2029603"}],"container-title":["Open Heart"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/openhrt-2026-004264","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T10:50:48Z","timestamp":1789555848000},"score":1,"resource":{"primary":{"URL":"https:\/\/openheart.bmj.com\/lookup\/doi\/10.1136\/openhrt-2026-004264"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":18,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,8,21]]},"published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1136\/openhrt-2026-004264"],"URL":"https:\/\/doi.org\/10.1136\/openhrt-2026-004264","relation":{},"ISSN":["2053-3624"],"issn-type":[{"value":"2053-3624","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]}}}