Timing of Antithrombotic Therapy Among Patients With Hemorrhagic Transformation After an Ischemic Stroke Publisher Pubmed



Hejazian S S ; Shahjouei S ; Bahrami S ; Vemuri A ; Dumitrascu O M ; Alvi M ; Annam S ; Koul P ; Pafumy J ; Singh A ; Rahimian N ; Reddy Lakki V B ; Palaiodimou L ; Badr A Show All Authors
Source: Journal of the American Heart Association Published:2026

Abstract

BACKGROUND: Evidence to guide the optimal timing of antiplatelet and oral anticoagulants (OACs) therapy after hemorrhagic infarction (HI) versus parenchymal hematoma (PH) is limited and inconsistent, leading to substantial variation in practice. This study's goal was to study the practice pattern and compare clinical outcomes associated with early-versus-delayed initiation of antiplatelet/OACs after hemorrhagic transformation (HT). METHODS: This multicenter, retrospective, cross-sectional study included patients with acute ischemic stroke and HT. Patients with an HI or PH were categorized by HT to antithrombotic initiation time, and their outcomes—30-day HT exacerbation, composite outcomes of recurrent stroke/systemic emboli, 90-day vascular death, and functional outcomes—were compared. RESULTS: Of 748 patients, 496 received antiplatelets, and 252 received OACs after HT. The median HT-to-antiplatelet time was significantly shorter after HI than PH (1 [interquartile range, 0–2] versus 3 [interquartile range, 1–5] days; P<0.001). There were no statistically significant differences in HT exacerbation and composite outcomes (30-day), as well as vascular death and unfavorable functional outcomes (90-day), between patients who received same-day, early (HI, <1 day; PH, <3 days), or late (HI, >1 day; PH, >3 days) antiplatelets after either HI or PH. Among patients on OACs, those with HI had shorter median HT-to-OAC time than PH (7 [interquartile range, 2–15] versus 15 [interquartile range, 7–32] days; P<0.001). Although HT exacerbation rates (30-day) were comparable between early (HI, <7 days; PH, <15 days) and late (HI, >7 days; PH, >15 days) OAC initiation after either HI or PH, late initiation after PH was accompanied by higher rates of composite outcomes (30-day) than early initiation (20.7% versus 3%; P=0.044). Regression models adjusted for demographics, National Institutes of Health Stroke Scale, and stroke severity showed no statistically significant association between early initiation of antiplatelets or OACs with HT exacerbation risk. CONCLUSIONS: Our study found no statistically significant difference in HT exacerbation between early and late initiation of antiplatelets or OACs among patients with HI/PH, while prolonged delay among patients with PH were accompanied by increased systemic thromboembolic events. Although these findings offer preliminary clinical insight, prospective studies are needed. © 2026, The Author(s). Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.