Undertreated hypertension: a major factor in intracranial haemorrhage-related mortality in anticoagulated patients with atrial fibrillation

Hypertension is a major modifiable risk factor for intracranial haemorrhage (ICH) in patients with atrial fibrillation (AF) taking oral anticoagulation (OAC) therapies. The prevalence of hypertension in AF is approximately 60-80% and progressively increases with age. In the context of advancing clinical frailty, inadequate management of hypertension may contribute substantially to the risk of ICH in this population.

Identification of the causative factors contributing to ICH-related mortality in patients with AF on OAC therapies.

Between December 2020 and April 2024, death registry data of a large district general hospital in the South-East of England, United Kingdom, was analysed to identify patients who were therapeutically anti-coagulated for AF with ICH as a primary cause of death. The confirmatory neuroimaging data was interrogated to assess the likely underlying cause of bleed.

Of the 5452 deaths within the study period, 46 patients on OAC for AF were included. 36 (78.3%) had spontaneous and 10 (11.7%) had traumatic ICH. 39 (84.8%) had recorded hypertension (80% in traumatic group, n = 8 Vs 86.1% in spontaneous ICH, n = 31). In those with spontaneous ICH, 28 (77.8%) demonstrated neuroradiological evidence of bleed as a result of hypertensive vasculopathy.

Hypertension is not only a major substrate of AF incidence but a cause of additional morbidity and mortality. We demonstrate a skewed distribution in the type of ICH to spontaneous rather than a traumatic aetiology, which is replicated in other studies. Within our cohort, hypertensive vasculopathy was a significant cause of spontaneous ICH-related mortality. Falls and trauma resulting in ICH in anticoagulated patients with AF may be overestimated. In line with the recently updated European Society of Cardiology (ESC) guideline, stringent blood pressure control should take priority in the management of AF to reduce major bleeding risk.