ANTITHROMBOTIC DRUGS AND RISK OF HEMORRHAGIC STROKE IN THE GENERAL POPULATION

et al.1 examined the risk of hemorrhagic stroke in patients treated with antithrombotics. While warfarin increased the risk of both intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), aspirin did not influence the risk of ICH and surprisingly decreased the frequency of SAH. The authors did not distinguish between SAH where an aneurysm was identified vs SAH where no aneurysm was found. This would have been use-ful as previous studies have indicated that aspirin may protect against aneurysm rupture.2 In addi-tion, the highest risk of ICH was found in the short-duration group of warfarin users. This may be due to maintaining a balanced control of anti-coagulation at the beginning of the treatment. Sim-ilar risk has been observed in recent trials comparing rivaroxaban to warfarin.3 It would be interesting to evaluate some characteristics of the patients ’ international normalized ratio trend—age or concomitant hypertension—to verify other pre-disposing factors vs the HAS-BLED score. The addition of an antiplatelet to warfarin does not increase the risk of ICH vs users taking only war-farin. Adding antiplatelets in patients taking warfarin and affected by acute ischemic events might be bene-ficial by reducing the risk of further thrombotic epi-sodes without the increase in cerebral bleeding risk. In this cohort study, it could be interesting also to identify characteristics (i.e., demographics and vascu-lar risk factors) of patients with ICH treated with antiplatelets and warfarin to detect a risk profile for cerebral hemorrhage. Finally, in this population-based study, the dual antiplatelet therapy (clopidogrel and aspirin) did not increase the risk of ICH significantly, which conflicts with previous clinical studies.4 This finding demon-strates that the “real world ” might be better in results than the “trial world.