title: The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis.
abstract: OBJECTIVE Although aspirin usage may be associated with a decreased risk of rupture of cerebral aneurysms, any potential therapeutic benefit from aspirin must be weighed against the theoretical risk of greater hemorrhage volume if subarachnoid hemorrhage (SAH) occurs. However, few studies have evaluated the association between prehemorrhage aspirin use and outcomes. This is the first nationwide analysis to evaluate the impact of long-term aspirin and anticoagulant use on outcomes after SAH. METHODS Data from the Nationwide Inpatient Sample (NIS; 2006-2011) were extracted. Patients with a primary diagnosis of SAH who underwent microsurgical or endovascular aneurysm repair were included; those with a diagnosis of an arteriovenous malformation were excluded. Multivariable logistic regression was performed to calculate the adjusted odds of in-hospital mortality, a nonroutine discharge (any discharge other than to home), or a poor outcome (death, discharge to institutional care, tracheostomy, or gastrostomy) for patients with long-term aspirin or anticoagulant use. Multivariable linear regression was used to evaluate length of hospital stay. Covariates included patient age, sex, comorbidities, primary payer, NIS-SAH severity scale, intracerebral hemorrhage, cerebral edema, herniation, modality of aneurysm repair, hospital bed size, and whether the hospital was a teaching hospital. Subgroup analyses exclusively evaluated patients treated surgically or endovascularly. RESULTS The study examined 11,549 hospital admissions. Both aspirin (2.1%, n = 245) and anticoagulant users (0.9%, n = 108) were significantly older and had a greater burden of comorbid disease (p < 0.001); severity of SAH was slightly lower in those with long-term aspirin use (p = 0.03). Neither in-hospital mortality (13.5% vs 12.6%) nor total complication rates (79.6% vs 80.0%) differed significantly by long-term aspirin use. Additionally, aspirin use was associated with decreased odds of a cardiac complication (OR 0.57, 95% CI 0.36%-0.91%, p = 0.02) or of venous thromboembolic events (OR 0.53, 95% CI 0.30%-0.94%, p = 0.03). Length of stay was significantly shorter (15 days vs 17 days [12.73%], 95% CI 5.22%-20.24%, p = 0.001), and the odds of a nonroutine discharge were lower (OR 0.63, 95% CI 0.48%-0.83%, p = 0.001) for aspirin users. In subgroup analyses, the benefits of aspirin were primarily noted in patients who underwent coil embolization; likewise, among patients treated endovascularly, the adjusted odds of a poor outcome were lower among long-term aspirin users (31.8% vs 37.4%, OR 0.63, 95% CI 0.42%-0.94%, p = 0.03). Although the crude rates of in-hospital mortality (19.4% vs 12.6%) and poor outcome (53.6% vs 37.6%) were higher for long-term anticoagulant users, in multivariable logistic regression models these variations were not significantly different (mortality: OR 1.36, 95% CI 0.89%-2.07%, p = 0.16; poor outcome: OR 1.09, 95% CI 0.69%-1.73%, p = 0.72). CONCLUSIONS In this nationwide study, neither long-term aspirin nor anticoagulant use were associated with differential mortality or complication rates after SAH. Aspirin use was associated with a shorter hospital stay and lower rates of nonroutine discharge, with these benefits primarily observed in patients treated endovascularly.
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Harvard Medical School, and.|H.T. Chan Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Hormuzdiyar H
authors.initials: HH
authors.lastname: Dasenbrock
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; and.
authors.forename: Sandra C
authors.initials: SC
authors.lastname: Yan
authors.affiliation: Barrow Neurological Institute, Division of Neurological Surgery, Phoenix, Arizona.
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Gross
authors.affiliation: Department of Neurological Surgery, Brigham and Women's Hospital.
authors.forename: Donovan
authors.initials: D
authors.lastname: Guttieres
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Harvard Medical School, and.
authors.forename: William B
authors.initials: WB
authors.lastname: Gormley
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Harvard Medical School, and.
authors.forename: Kai U
authors.initials: KU
authors.lastname: Frerichs
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Harvard Medical School, and.
authors.forename: M
authors.initials: M
authors.lastname: Ali Aziz-Sultan
authors.affiliation: Cushing Neurosurgical Outcomes Center.|Department of Neurological Surgery, Brigham and Women's Hospital.|Harvard Medical School, and.
authors.forename: Rose
authors.initials: R
authors.lastname: Du
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use*; D004334:Drug Administration Schedule; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
keywords: CI = confidence interval; COX = cyclooxygenase inhibitor; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; IQR = interquartile range; ISUIA = International Study of Unruptured Intracranial Aneurysms; NIS = Nationwide Inpatient Sample; NIS-SAH SS = NIS-SAH severity scale; NIS-SOM = NIS-SAH outcome measure; SAH = subarachnoid hemorrhage; acetylsalicylic acid; anticoagulant; anticoagulation; aspirin; cerebral aneurysm; endovascular; mRS = modified Rankin Scale; subarachnoid hemorrhage; vascular disorders