Antiplatelets may be safe after intracerebral bleeding

Antiplatelet treatment reduces the risk of major vascular event, but people surviving intracerebral haemorrhage are at risk of both haemorrhagic and occlusive vascular events: it is unclear if antiplatelet therapy can be used safely for these people. The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial that recruited adults taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Researchers followed the subjects for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. 537 participants were recruited for a median duration of 76 days after intracerebral haemorrhage, and randomly assigned to start or avoid antiplatelet therapy. Participants were followed for a median of 2·0 years. 12 (4%) of 268 participants who got antiplatelets had a recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid the drugs (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). This study, recently published in The Lancet, suggests that the benefits of antiplatelet treatment after intracerebral bleeding probably still outweigh the risks. There is probably still work to do to clarify the implications of these results, but any information is welcome where hitherto it did not exist to guide practice.