Timing of vitamin K antagonist re-initiation following intracranial hemorrhage in mechanical heart valves: Systematic review and meta-analysis

Recommencing anticoagulation treatment in surgically managed patients with intracerebral haemorrhage and mechanical heart valves: An Aotearoa-New Zealand analysis

PURPOSE

Intracerebral haemorrhage (ICH) is an absolute contraindication for therapeutic oral anticoagulation therapy (OAT). Re-bleeding carries significant risk of morbidity and mortality. Patients with prosthetic heart valves are at higher risk of thromboembolic complications when OAT is withheld. The aim of our study is to establish the safe time periods where OAT can recommence, and assess the complication rates of re-introduction and associated risk factors.

METHODOLOGY

New Zealand-wide, retrospective (2005-2021) and prospective (2021-2023) data was collected from patients with prosthetic heart valves, aged 18 years or older who underwent surgical management of ICH. The time to re-bleeding or thromboembolic event was recorded and the time period that balances the risks was examined. Primary outcomes included rate of re-bleeding and thromboembolic events. Associated medical, radiological, surgical and valve risk factors were examined.

RESULTS

Thirty patients were identified and included in the analysis. Average time to therapeutic anticoagulation was 12.2 days post-op (95 % CI 6.9 - 17.5 days), 62.5 % recommenced OAT at or before day 14 (Range 3-13 days). Four patients (13.3 %) sustained a re-bleeding event after recommencing OAT. Three of the 4 re-bleeding events were observed in the group recommencing prior day 14, without reaching statistical significance. Of these, two patients died following the event. Group mortality was 30 %. One patient had a thromboembolic complication at day 14 post OAT, age of valve was 2 months. No thromboembolic complications were observed in patients recommencing after day 14. Maori and Pasifika patients were disproportionately represented and their condition was associated with a background of Rheumatic Heart Disease in 10 out of 11 cases.

CONCLUSION

Early re-commencing of OAT is effective in preventing thromboembolic complications associated to prosthetic heart valves. There is a tendency for re-bleeding to occur when OAT is recommenced prior to day 14 (not significant). These data suggest that in this New Zealand cohort, the thromboembolic risks of withholding OAT may be overestimated at the expense of early anticoagulation, with an increased risk of re-bleeding in this surgically managed cohort. Further prospective studies are warranted to definitively examine the risks of early therapeutic anticoagulation in this group.

Resumption of anticoagulation therapy after spontaneous intracerebral hemorrhage with patients mechanical heart valves

Background

Patients with mechanical heart valves are usually maintained on anticoagulation therapy. However, after a spontaneous intracerebral hemorrhage event, administration of anticoagulants is temporarily ceased, and it remains unclear when to restart anticoagulation therapy.

Methods

A cohort study was conducted to investigate the optimal time for restarting anticoagulation in patients with mechanical heart valves after spontaneous intracerebral hemorrhage. All patients with mechanical valves who experienced spontaneous cerebral hemorrhage and were admitted to the Second Affiliated Hospital of the Zhejiang University Medical School between 2013 and 2018 were retrospectively enrolled in this study. The patient electronic medical records were reviewed and the correlation between the time of restarting anticoagulation (within 3 days or more than 3 days after hemorrhage) and patient prognosis was assessed.

Results

A total of 40 patients with mechanical heart valves who experienced spontaneous cerebral hemorrhage were enrolled in this study. All patients were given oral warfarin anticoagulant therapy prior to admission (1.5–3.25 mg). After admission, patients were administered fresh frozen plasma and/or vitamin K1 to reverse anticoagulation. Out of the 16 patients (40%) who underwent surgical intervention, 4 died from cerebral hemorrhage deterioration during the hospital stay and did not restart anticoagulant therapy. Anticoagulant therapy was resumed within 3 days for 18 patients and more than three days after hemorrhage for the other 18 patients. After discharge, patients were followed up for 12 months or more. Unfortunately, during this period, 17% of patients (6/36) died.

Conclusions

Definitive hemostatic measures can be as an important factor in the clinical resumption of anticoagulation. Halting anticoagulant therapy for 3 to 7 days may be safe. It is recommended that low molecular heparin be administered within 3 days as a bridge treatment, combine with warfarin anticoagulant therapy within 1 week after hemorrhage.

Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves

Valvular heart disease is common in the United States, with a number of patients undergoing valve replacement procedures every year. The two types of valve prostheses include mechanical and bioprosthetic valves. Mechanical heart valves require lifelong anticoagulation with vitamin K antagonists like warfarin. The clinicians are often faced with the dilemma of major bleeding episodes such as intracranial hemorrhage or gastrointestinal bleeding in these patients. The management includes reversing warfarin-induced coagulopathy with vitamin K supplementation, fresh frozen plasma, or prothrombin complex concentrate (PCC), with PCC being the treatment of choice. With regard to the safe resumption of anticoagulation, guidelines are silent, and data is limited to case reports/series. This article reviews the present literature for the management of bleeding in patients with mechanical heart valves and the safe duration for holding off anticoagulation with minimal risk of valve thrombosis/thromboembolism.

Anticoagulation therapy in atrial fibrillation after intracranial hemorrhage

Intracerebral hemorrhage (ICH) is severe and fatal complication of anticoagulant therapy with an incidence 0.3-0.7% per year. For patients with atrial fibrillation (AF) anticoagulants are administered for decreasing risk of stroke and systemic embolism. In this case the occurrence of intracranial bleeding is hard task for doctor. From the one side it is necessary to reverse the action of the drug for preventing the growth of hematoma. At the same time the discontinuation of therapy increases the risk of systemic embolism for patients with AF significantly. Clinical guidelines and studies have been reviewed about ICH during anticoagulant therapy. Nowadays there is no quality evidence about reversal of anticoagulant effects after ICH and optimal time of resumption of anticoagulant therapy. Firstly, we do not have large randomized controlled trials on this issue. The majority of clinical guidelines were based on retrospective studies and opinions of experts. Soon several randomized controlled trials will be finished and new data will be presented.

Long-term outcome of resuming anticoagulation after anticoagulation-associated intracerebral hemorrhage

Introduction

The risk and benefit of restarting oral anticoagulation (OAC) therapy among patients with atrial fibrillation or flutter (AF) and an episode of anticoagulation-associated intracerebral hemorrhage (ICH) remain unclear. Whether or not to resume OAC after an OAC-associated ICH will remain an unanswered clinical question until we have sufficient data through randomized clinical trials. Here, we analyzed the long-term outcome of patients with AF who did or did not resume OAC after an OAC-associated ICH.

Patients and methods

We studied consecutive patients with AF who were discharged from our institution after an OAC-associated ICH event between 2010 and 2017. Baseline characteristics of patients, past medical history, and history or OAC use were recorded. Outcome measures in our study included recurrent ICH, ischemic stroke or systemic emboli, and death.

Results

Out of 115 patients with AF and OAC-associated ICH, 93 patients (mean age 76.2 ± 10.3 years [44–91 years old], 54.3% men) were included in this study. Thirty-eight (40.9%) patients resumed OAC after the episode of OAC-associated ICH. More than 70% of patients had resumed OAC within two months of ICH (mean delay 56.0 ± 52.5 days). There was no significant difference between the group who resumed OAC and the group who did not in terms of mean follow-up duration (1.9 vs. 2.4 years), the type of initial ICH, as well as history of hypertension, diabetes, previous ischemic stroke, congestive heart failure, coronary artery disease, and tobacco use. There was no significant difference between the two groups considering the incidence rate of recurrent ICH (relative risk 2.9; 95% CI, 0.3–30.8). There was also no significant difference between the two groups regarding the incidence rate of ischemic stroke or systemic emboli (relative risk 0.9; 95% CI, 0.3–2.7). There was no significate difference between patients who did and did not resume OAC was 96 and 121 per 1000 patient-years, respectively (relative risk 0.8; 95% CI, 0.3–1.9).

Conclusions

We did not observe any significant difference between the group of patients who resumed OAC and the patients who did not in terms of recurrent ICH, ischemic stroke or systemic emboli, and death. However, there was a tendency toward a higher long-term risk of recurrent ICH among patients who resumed OAC.

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Outcome of AF patients who did/did not resume OAC after an OAC-ICH was studied.

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No significant difference between two groups in terms of recurrent ICH and death.

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Tendency toward a higher long-term risk of recurrent ICH in patients who resumed OAC.

Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Aims

Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH.

Methods and results

We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03).

Conclusion

Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk.

Direct-Acting Oral Anticoagulants and Warfarin-Associated Intracerebral Hemorrhage Protocol Reduces Timing of Door to Correction Interventions

BACKGROUND

Intracerebral hemorrhage (ICH) is a life-threatening complication of oral anticoagulant therapy that sometimes results in hematoma expansion after onset. Our facility did not have a standardized process for treating oral anticoagulant-associated ICH; this resulted in lag times from order to reversal agent administration.

PURPOSE

The aim of this study was to examine the impact of a rapid anticoagulant reversal protocol, combined with warfarin and direct-acting oral anticoagulant therapy, in decreasing door to first intervention times.

METHODS

This study used a retrospective quality assessment research approach in examining an oral anticoagulant reversal protocol to compare the control and intervention groups. Phytonadione was the first intervention treatment for most study participants diagnosed with warfarin-associated ICH with an international normalized ratio greater than 1.4. Factor IX was the first intervention treatment for all but one study participant with DOAC-associated ICH.

RESULTS

Findings were statistically significant (P < .05) for door to first intervention treatments. Door to phytonadione in minutes decreased from 232.7 (SD, 199.4) to posttest findings of 111.4 (SD, 64.6). Door to factor IX in minutes decreased from 183.9 (SD, 230.2) to posttest findings of 116.6 (SD, 69.1).

CONCLUSION

Study findings support the hypothesis that the new protocol was associated with lower door-to-treatment times for eligible patients.

Reversal of Anticoagulants in Critical Care

There has seen an increase in anticoagulant consumption worldwide over the past few decades. With this widespread utilization of anticoagulants, clinicians are increasingly likely to encounter situations where anticoagulants would need to be withheld. This includes emergency and elective procedures or surgeries as well as major or minor bleeding as a direct result of over anticoagulation or consequent to other intercurrent illnesses such as sepsis or trauma with multiorgan failure, where the anticoagulant may contribute to coagulation abnormalities. Clinicians are required to have a thorough understanding of the indications for anticoagulant prescription, drug interactions and monitoring, indications and options of reversal of anticoagulation and management of bleeding in the situations described above. Once the acute process is managed, the ongoing need and timing of reinitiation of anticoagulation is also crucial. This article provides an overview on the indications for reversal of anticoagulation, the agents used for reversal and the timing of reinitiation of anticoagulants.

Postoperative Anticoagulation After Neurologic Surgery

Management of anticoagulation and antiplatelet medications after neurosurgery can be complex, especially given that these patients have multiple medical comorbidities. In turn, neurosurgical patients are at high risk for the development of venous thromboembolism after surgery, so neurosurgeons must consider the use of pharmacologic prophylaxis. Developments in endovascular neurosurgery have produced therapies that require close management of antiplatelet medications to prevent postoperative complications. Any of these patient populations may need intrathecal access. This article highlights current strategies for managing these issues in the neurosurgical patient population.

The reversal of anticoagulation in clinical practice

Widespread use of anticoagulant drugs for treatment and -prevention of thromboembolic events means it is common to encounter patients requiring reversal of anticoagulation for management of bleeding or invasive procedures. While supportive and general measures apply for patients on all agents, recent diversification in the number of licensed agents makes an understanding of drug-specific reversal strategies essential. Recognising effects upon, and limitations of, laboratory measures of coagulation also plays an important role. An understanding of reversal strategies alone is insufficient to competently care for patients who may require anticoagulation reversal. It is also necessary to reduce the need for reversal through correct prescribing and by employing appropriate periprocedural bridging strategies for elective and semi-elective procedures. Finally, consideration of whether and when to reintroduce an anticoagulant drug following reversal is important not only to balance bleeding and thrombotic risks for individual patients but also for timely management of discharge.

Resuming anticoagulants after anticoagulation-associated intracranial haemorrhage: systematic review and meta-analysis

OBJECTIVE

To determine the adverse outcomes following resumption of anticoagulation in patients with anticoagulation-associated intracranial haemorrhage (ICH).

DESIGN

We performed a systematic review and meta-analysis in this clinical population. The Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement was followed, and two authors independently assessed eligibility of all retrieved studies and extracted data.

DATA SOURCES

Medline, Embase and the Cochrane Central Register of Controlled Trials, from inception to February 2017.

ELIGIBILITY CRITERIA AND OUTCOMES

Randomised controlled trials or cohort studies that recruited adults who received oral anticoagulants at the time of ICH occurrence and survived after the acute phase or hospitalisation were searched. Primary outcomes, including long-term mortality, recurrent ICH and thromboembolic events. Secondary outcomes were the frequency of resuming anticoagulant therapy and related factors.

RESULTS

We included 12 cohort studies (no clinical trials) involving 3431 ICH participants. The pooled frequency of resuming anticoagulant therapy was 38% (95% CI 32% to 44%), but this was higher in participants with prosthetic heart valves, subarachnoid haemorrhage or dyslipidaemia. There was no evidence that resuming anticoagulant therapy was associated with higher long-term mortality (pooled relative risk (RR) 0.60, 95% CI 0.30 to 1.19; p=0.14) or ICH recurrence (pooled RR 1.14, 95% CI 0.72 to 1.80; p=0.57). Resumption of anticoagulation was associated with significantly fewer thromboembolic events (pooled RR 0.31, 95% CI 0.23 to 0.42; p<0.001). In a subgroup of patients with atrial fibrillation, resuming anticoagulant therapy was associated with fewer long-term mortality (pooled RR 0.27, 95% CI 0.20 to 0.37, p<0.001).

CONCLUSIONS

Based on these observational studies, resuming anticoagulant therapy after anticoagulation-associated ICH has beneficial effects on long-term complications. Clinical trials are needed to substantiate these findings.

PROSPERO REGISTRATION NUMBER

CRD42017063827.

[Intracranial hemorrhage and oral anticoagulants of patients treated between 2011 and 2013 at the Nancy Regional University Hospital]

OBJECTIVE

To perform a descriptive analysis of intracranial hemorrhages of patients treated with an antivitamin K (fluindione, acenocoumarol or warfarin) or a direct oral anticoagulant (dabigatran, rivaroxaban or apixaban) at the Nancy Regional University Hospital.

MATERIAL AND METHOD

The study period was from January 2011 to December 2013 and the computerized data (Programme de Médicalisation des Systèmes d'Information) of our hospital was accessed to identify the patients. Clinical data were obtained from the patients' files. Regional healthcare system was queried for reimbursement data.

RESULTS

Among the 157 identified cases of intracranial hemorrhage, 153 were related to antivitamin K, primarily fluindione (n=127), and only 4 to a direct oral anticoagulant (3 dabigatran and 1 rivaroxaban). During the same period, regional data indicated that 65,345 patients had had at least one reimbursement of antivitamin K and 20,983 patients one reimbursement of an oral direct anticoagulant. In our series, the most frequent intracranial hemorrhages were subdural hematoma (chronic in 65 cases, acute in 50 cases) and intraparenchymal hemorrhage (20 cases). The global mortality rate was 20.2% but varied with the site of hemorrhage. In multivariate analysis, the two risk factors of fatal outcome were coma on admission (OR 6.2; 95%CI: 2.6-15.0) and a history of previous intracranial hemorrhage (OR 13,4; 95% CI: 1,6-114,9).

CONCLUSION

During the 2011-2013 period, antivitamin K, especially fluindione, was the most frequently involved anticoagulants in intracranial hemorrhages with hospitalization at our Regional University Hospital. Coma on admission and a history of previous intracranial hemorrhage were the two main risk factors for fatal outcome.