Characterizing risk of stroke following anticoagulation reversal in patients with prior intracranial hemorrhage and heart valves

1. In a cohort of patients with mechanical heart valves and a prior history of intracranial hemorrhage (ICH), the risk of thromboembolism, ischemic stroke, and valve thrombosis was low following anticoagulation reversal therapy (PCC or FFP) 

2. The timing of anticoagulation reinitiation was not associated with the risk of ICH expansion however bridging with IV heparin increased the risk of ICH

Evidence Rating Level: 2 (Good) 

In patients with intracranial hemorrhage (ICH) and mechanical heart valves, the optimal time for reinitiation of oral anticoagulation is unknown. For patients with ICH, reversal of anticoagulation is essential for treatment. In patients with mechanical heart valves, the risk of thromboembolic events after anti-coagulation reversal is unknown. Keeping these patients off anticoagulants can incur a significant risk of ischemic stroke or systemic embolism. This large retrospective observational cohort study included patients with mechanical heart valves that had previous ICH. The aim was to investigate the effect of reversal therapy and ischemic stroke, the duration of anticoagulation and risk of ischemic stroke or systemic embolism, and the timing of anticoagulation resumption and risk of rebleeding and ICH expansion. The primary end points of the study were thromboembolic events while off anticoagulation and ICH expansion after anticoagulation resumption. 171 patients were identified who had both ICH and a mechanical heart valve. The mean age of the participants was 72 years old with 68% of them being men. There was no significant increase in risk of ischemic stroke or systemic embolism in patients who received anticoagulation reversal therapy. Additionally, there was no difference between the method of reversal therapy (prothrombin complex concentrate or fresh-frozen plasma). Time off of anticoagulation was not associated with ischemic stroke or TIA occurrence. Most patients who developed a stroke after being off anticoagulation did so after 7 days. All patients who developed a stroke earlier had additional risk factors. ICH expansion after anticoagulation resumption occurred in 17 patients (9.9%). The timing of anticoagulation resumption was not associated with risk of ICH expansion (p = 0.41). Heparin was a bridging anticoagulation therapy in 49 patients but resulted in a significantly higher rate of ICH compared to patients started on warfarin (p = 0.004). 

Click to read the study in Neurology

Image: PD

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