The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial

Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage

“…With regard to optimal timing, our analysis focused on DTT times because emergency department–based acute care is an established environment for time-dependent quality improvement in stroke . Indeed, 2 recent studies in the UK and Eastern hemisphere incorporated warfarin reversal strategies into a quality improvement bundle intervention within 90 and 60 minutes, respectively . In the present analysis, DTT times of less than 60 minutes most clearly demonstrated a time-dependent effect of coagulopathy reversal, but we cannot exclude an even greater effect with earlier initiation.…”

“…Prior clinical trials of coagulopathy reversal have demonstrated a reduction in ICH expansion and improved clinical outcome . However, there was not sufficient precision or power to establish the presence of a time-dependent effect.…”

“…3,4 Prior clinical trials of coagulopathy reversal have demonstrated a reduction in ICH expansion and improved clinical outcome. 5,6 However, there was not sufficient precision or power to establish the presence of a time-dependent effect. In an observational multicenter study, earlier (less than 4 hours after hospital arrival) reversal of VKA was associated with a significant reduction in ICH expansion and lower in-hospital mortality, but timing of reversal therapy was not assessed.…”

Code ICH: A Call to Action

“…70 More recently, the INTERACT-3 trial evaluated the effectiveness of a care bundle of intensive BP lowering (target systolic BP <140 mm Hg), correction of hyperglycemia, fever control, and reversal of anticoagulation within 1 hour of emergency department admission in 7036 patients with ICH presenting within 6 hours of onset. 71 The trial used a step-wedge cluster (hospital)randomized trial design in which hospitals successively switched from conventional management to implementation of the care bundle, resulting in an even distribution of patients on completion of the study. The likelihood of poor functional outcome at 6 months evaluated using a modified Rankin Scale shift analysis was lower in the care bundle group (common OR, 0.86 [95% CI, 0.76-0.97]; P=0.015).…”

“…The landmark INTERACT-3 trial now adds further evidence that early intensive BP lowering can reduce the likelihood of poor functional outcome. 71 In patients with ICH, every 1 mL of HE leads to a 5% increase in the odds of death or dependence. 7 This means that HE of 10 mL after baseline CT results in a 55% higher odds of mortality or increased morbidity.…”