Anticoagulant Use Associated With Bleeding After Young Adult Stroke

Young adults after ischemic stroke had a 5-year cumulative bleeding risk of 10.7%, according to a prospective cohort study published in JAMA Network Open.

The investigators noted that antithrombotic therapy is routinely prescribed to young stroke survivors to prevent recurrent vascular events, but that the long-term balance of benefits and bleeding risks in this population remains uncertain. They added that secondary prevention strategies are based on trials in older populations in which younger patients were underrepresented.

The analysis used data from the Observational Dutch Young Symptomatic Stroke Study (ODYSSEY), conducted at 17 hospitals in the Netherlands. It included 1226 patients aged 18 to 49 years with a first-ever, neuroimaging-proven ischemic stroke who survived the first 30 days. The primary outcome was a bleeding event requiring medical evaluation, classified by Bleeding Academic Research Consortium (BARC) criteria. Over a median follow-up of 4.2 years, 129 patients had at least 1 bleeding event, for an annual rate of 2.5 events per 100 person-years. Among patients receiving antiplatelet therapy, the 6-year cumulative risk of bleeding exceeded that of recurrent vascular events (14.7% vs 12.9%). Among those receiving oral anticoagulants, the 5-year risks were 24.0% and 23.6%, respectively.

In multivariable analysis, female sex (hazard ratio [HR], 3.39; 95% CI, 2.12-5.41), cardioembolic stroke cause (HR, 2.17; 95% CI, 1.14-4.14), and anticoagulant therapy (HR, 3.07; 95% CI, 1.34-7.07) were independently associated with bleeding. The higher risk in women was primarily driven by gynecologic bleeding, and female sex was not significantly associated with bleeding when gynecologic events were excluded. Nine patients had a major bleed, and no deaths were attributed to bleeding.

The authors noted that events may have been underreported through follow-up questionnaires and that data on medication adherence and on functional outcomes after bleeding or recurrent stroke were not available. They concluded that bleeding risk should be carefully considered throughout long-term antithrombotic therapy.

Source: Rasing A, Verburgt E, Ekker MS, et al. Antithrombotic therapy and bleeding risk among young adults after ischemic stroke. JAMA Netw Open. 2026;9(9):e2635826. doi:10.1001/jamanetworkopen.2026.35826

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