Bleeding risk rivals recurrent events after stroke in younger adults

Clinical takeaway: When counseling younger ischemic stroke survivors about long-term antithrombotic therapy, discuss bleeding risk alongside recurrent stroke prevention, particularly in patients receiving anticoagulants or those with cardioembolic stroke.

Antiplatelet agents and anticoagulants are routinely prescribed after ischemic stroke, often for life. Yet most evidence guiding long-term therapy comes from older populations, leaving uncertainty about how bleeding risk accumulates over decades in younger adults.

In this Dutch prospective cohort study, investigators followed 1,226 adults aged 18 to 49 years who survived a first ischemic stroke for a median of 4.2 years. During follow-up, 129 patients experienced at least one bleeding event requiring medical evaluation, yielding a 5-year cumulative bleeding risk of 10.7% and an annual bleeding rate of 2.5 events per 100 person-years. Most bleeding events were minor, and major bleeds occurred in fewer than 1% of participants; no deaths were attributed to bleeding.

Patients receiving oral anticoagulants experienced more than twice as many bleeding events as those taking antiplatelet therapy (5.2 vs 2.3 events per 100 person-years). Bleeding risk was also higher among patients with cardioembolic stroke. Women experienced more bleeding events than men, largely because of gynecologic bleeding.

Notably, bleeding risk eventually matched or exceeded the risk of recurrent vascular events. Among patients receiving antiplatelet therapy, cumulative bleeding risk reached 14.7% at 6 years compared with a 12.9% risk of recurrent vascular events. In those receiving anticoagulants, bleeding risk reached 24.0% at 5 years, slightly exceeding the 23.6% risk of recurrent vascular events.

“These findings highlight that bleeding risk should be carefully considered throughout long-term antithrombotic therapy,” the authors wrote.

Source: Rasing A, et al. (2026 Sep 24) JAMA Netw Open. Antithrombotic Therapy and Bleeding Risk Among Young Adults After Ischemic Stroke