A 70-year-old man with atrial fibrillation and a CHA2DS2-VASc score of 4 is prescribed anticoagulation. He develops a fall-related intracranial haemorrhage on warfarin with INR 2.6. After recovery, which anticoagulation option is MOST appropriate on reassessment?

• A Discontinue all anticoagulation permanently given the ICH
• B Resume warfarin at lower INR target of 1.5-2.0
• C Use antiplatelet therapy (aspirin + clopidogrel) instead
• D Switch to a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban after 4-8 weeks ✓

Explanation

After intracranial haemorrhage in AF patients, resuming anticoagulation is generally recommended after 4-12 weeks depending on ICH cause and haemostasis, as the ongoing stroke risk from AF typically outweighs re-bleeding risk. DOACs (particularly apixaban) have shown significantly lower rates of ICH compared to warfarin in AF trials (ARISTOTLE, ROCKET-AF, RE-LY). Lower INR targets are not validated and provide inadequate stroke protection. Dual antiplatelet therapy in AF increases bleeding without equivalent stroke prevention compared to anticoagulation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.