Anticoagulant Reversal, Blood Pressure, and Anticoagulant Resumption in Intracerebral Hemorrhage | Journal Scan

Study Questions:

What are the associations between anticoagulation reversal and blood pressure with respect to hematoma enlargement and resumption of oral anticoagulation?

Methods:

The authors performed a retrospective cohort study at 19 tertiary care centers in Germany between 2006 and 2012. They identified 1,176 individuals who suffered an oral anticoagulant-related intracerebral hemorrhage. Identified patients were assessed for anticoagulant reversal in the acute phase, systolic blood pressure at 4 hours, and re-initiation of oral anticoagulation for long-term therapy. Subgroups analyzed included 853 for hematoma enlargement and 719 for oral anticogulant resumption. Outcomes assessed included hematoma enlargement, in-hospital mortality, long-term ischemic and hemorrhagic events, and long-term mortality.

Results:

Hematoma enlargement occurred in 307/853 (36.0%) patients. Reduced rates of hematoma enlargement were associated with a successful international normalized ratio (INR) reversal to <1.3 within 4 hours after admission (19.8% vs. 41.5%, p < 0.001) and systolic blood pressure <160 mm Hg at 4 hours (33.1% vs. 52.4%, p < 0.001). The combination of both measures as compared to one or fewer measure was associated with reduced odds of hematoma enlargement (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.19-0.42) and in-hospital mortality (OR, 0.60; 95% CI, 0.37-0.95). Oral anticoagulants were resumed in 172/719 (23.9%) survivors. Patients who resumed oral anticoagulation had fewer ischemic complications (5.2% vs. 15.0%, p < 0.001) without any increase in hemorrhagic complications (8.1% vs. 6.6%, p = 0.48). Propensity-matched analysis in atrial fibrillation patients who restarted oral anticoagulants showed a decreased hazard for mortality (HR, 0.26; 95% CI, 0.13-0.53).

Conclusions:

The authors concluded that among patients who suffer an oral anticoagulant-related intracerebral hemorrhage, reversal of INR to <1.3 within 4 hours and systolic blood pressure <160 mm Hg within 4 hours is associated with lower rates of hematoma enlargement and in-hospital mortality. They also concluded that the resumption of oral anticoagulant therapy is associated with a lower risk of ischemic complications and long-term mortality without an increase in hemorrhagic complication risks.

Perspective:

The authors performed an important analysis of over 1,100 patients who suffered an oral anticoagulant-related intracranial hemorrhage. They were able to identify three key parameters for improving outcomes following an intracranial hemorrhage. The first two (INR reversal and systolic blood pressure control) are critical initial targets that can be targeted in the emergency department and intensive care units. The third (resumption of oral anticoagulation) is perhaps the most challenging, as many patients and providers are nervous about restarting an anticoagulant after a significant hemorrhagic complication. While the limitations of retrospective cohort studies must be taken into consideration, this study provides further evidence that at-risk individuals do better when oral anticoagulants are resumed rather than omitted following a major bleeding event. While prospective studies to confirm these findings would be welcomed, practitioners should strongly consider the benefits of resuming anticoagulant therapy in all patients who experience a major bleeding event once the bleeding source is stabilized or resolved. This is of utmost importance for atrial fibrillation patients due to their increased risk of ischemic stroke.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Cerebral Hemorrhage, Hemorrhage, Blood Pressure, Hematoma, Atrial Fibrillation, International Normalized Ratio, Tertiary Care Centers, Hospital Mortality, Cohort Studies, Retrospective Studies, Secondary Prevention


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