Resuming anticoagulant therapy after intracerebral bleeding

Becattini, Cecilia; Sembolini, Agnese; Paciaroni, Maurizio

doi:10.1016/j.vph.2016.05.012

Cited by 16 publications

(12 citation statements)

References 121 publications

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“…Furthermore, DOACs are associated with reductions in ICH, therein favoring their use in neurodegenerative diseases and in elderly patients. 46…”

Section: Resultsmentioning

confidence: 99%

“…45 Early anticoagulant restarting may be optimal; however, individualized evaluations need to be carried out for all patients prior to selecting anticoagulant resumption time and intensity. 46 In addition, hypertension must be monitored as well as diabetes and other risk factors that are known to increase hemorrhagic risk. Hematologist’s consultation is advisable to identify malignancies or other potential causes of hemorrhagic diathesis.…”

Section: During Doacs Therapymentioning

confidence: 99%

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Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists

Canavero

Micieli

Paciaroni

2017

Clin Appl Thromb Hemost

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Direct oral anticoagulants (DOACs) are valid alternative options to vitamin K antagonists due to their limited interactions with drugs or food and the fact that they do not require regular coagulation monitoring. To this regard, recent practice guidelines recommend that DOACs should be considered as first-line anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). This review (1) outlines current international guidelines for the management of DOACs to prevent stroke in patients with NVAF, (2) outlines indications for elderly patients as well as specific settings including acute coronary syndromes and intracranial hemorrhage, and (3) offers a practical guide for the use of DOACs in neurological settings.

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“…Furthermore, DOACs are associated with reductions in ICH, therein favoring their use in neurodegenerative diseases and in elderly patients. 46…”

Section: Resultsmentioning

confidence: 99%

Section: During Doacs Therapymentioning

confidence: 99%

Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists

Canavero

Micieli

Paciaroni

2017

Clin Appl Thromb Hemost

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“…We do not dispute that only the results of randomized, controlled trials will be able to provide clinically useful indications on whether and when to prescribe antithrombotic agents to ICH survivors, and whether DOACs can be used with less concerns about bleeding complications compared with warfarin, at least in patient with nonvalvular atrial fibrillation. 23 However, several selection biases may potentially reduce these trials' overall external validity, an aspect that should be considered when translating their results into clinical practice and guidelines. 24,25 For the time being, therefore, our observational data from a real-world patient population support the hypothesis that while restarting anticoagulation after cerebral haemorrhage can be considered for secondary medical prophylaxis in patients at risk of thromboembolism without offsetting patient safety, a nihilistic approach appears not warranted.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulants Resumption after Warfarin-Related Intracerebral Haemorrhage: The Multicenter Study on Cerebral Hemorrhage in Italy (MUCH-Italy)

et al. 2018

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Whether to resume antithrombotic treatment after oral anticoagulant-related intracerebral haemorrhage (OAC-ICH) is debatable. In this study, we aimed at investigating long-term outcome associated with OAC resumption after warfarin-related ICH, in comparison with secondary prevention strategies with platelet inhibitors or antithrombotic discontinuation. Participants were patients who sustained an incident ICH during warfarin treatment (2002-2014) included in the Multicenter Study on Cerebral Hemorrhage in Italy. Primary end-point was a composite of ischemic stroke/systemic embolism (SE) and all-cause mortality. Secondary end-points were ischemic stroke/SE, all-cause mortality and major recurrent bleeding. We computed individual propensity score (PS) as the probability that a patient resumes OACs or other agents given his pre-treatment variables, and performed Cox multivariable analysis using Inverse Probability of Treatment Weighting (IPTW) procedure. A total of 244 patients qualified for the analysis. Unlike antiplatelet agents, OAC resumption was associated with a lower rate of the primary end-point (weighted hazard ratio [HR], 0.21; 95% confidence interval [CI], 0.09-0.45), as well as of overall mortality (weighted HR, 0.17; 95% CI, 0.06-0.45) and ischemic stroke/SE (weighted HR, 0.19; 95% CI, 0.06-0.60) with no significant increase of major bleeding in comparison with patients receiving no antithrombotics. In the subgroup of patients with atrial fibrillation, OACs resumption was also associated with a reduction of the primary end-point (weighted HR, 0.22; 95% CI, 0.09-0.54), and the secondary end-point ischemic stroke/SE (weighted HR, 0.09; 95% CI, 0.02-0.40). In conclusion, in patients who have an ICH while receiving warfarin, resuming anticoagulation results in a favorable trade-off between bleeding susceptibility and thromboembolic risk.

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“…An observational study demonstrated that early OAC resumption (<2 weeks) could not improve the composite outcome (i.e., thromboembolic events, major bleeding events, and all-cause mortality), particularly because of an increased risk of major bleeding events [ 20 ]. Given these risks, some researchers have suggested that OAC should be avoided in the first 2 weeks after OAC-associated parenchymal ICH and resumption at 4 weeks if the cause of ICH has been amended or in patients with small ICH and high thromboembolic risk [ 63 ].…”

Section: Timing Of Restarting Oacmentioning

confidence: 99%

“…Hence, the timing of OAC restarting depends on individual clinical condition (i.e., the risks of thromboembolism and likelihood of recurrent ICH). For example, in patients with brainstem or cerebellar ICH, the timing should be delayed at least 8–10 weeks after the event [ 63 ]. On the other hand, in patients with prosthetic mechanical valves, who have a (very) high risk of thromboembolism, OAC is suggested to be resumed at 2 weeks after the onset of ICH or sooner if the hemorrhage burden is small and causative mechanism treated or stabilized.…”

Section: Timing Of Restarting Oacmentioning

confidence: 99%

Anticoagulation Resumption After Intracerebral Hemorrhage

Lip

2018

Curr Atheroscler Rep

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Purpose of reviewDecision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH.Recent findingsOAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives.SummaryGiven the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.

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Resuming anticoagulant therapy after intracerebral bleeding

Cited by 16 publications

References 121 publications

Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists

Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists

Anticoagulants Resumption after Warfarin-Related Intracerebral Haemorrhage: The Multicenter Study on Cerebral Hemorrhage in Italy (MUCH-Italy)

Anticoagulation Resumption After Intracerebral Hemorrhage

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