Oral Anticoagulant-Related Hemorrhage: Improving Management of a Risky Condition

Seemant Chaturvedi, MD reviewing Kuramatsu JB et al. JAMA 2015 Feb 24.

Reversal of anticoagulation within 4 hours, systolic blood pressure ≤160 mm Hg, and resumption of anticoagulants are associated with better outcomes.

Use of oral anticoagulant medication (OAC) is expected to increase substantially in the next decades due to the large burden of atrial fibrillation in an aging population. As a complication of OAC use, intracerebral hemorrhage (ICH) can be devastating, with rates of morbidity and mortality exceeding 60%. Practical advice on improving the management of patients with OAC-related ICH is welcome. Using data on 1176 patients with OAC-related ICH from 19 tertiary centers in Germany (mean age, 74; men, 59%), researchers examined factors associated with hematoma enlargement (analyzed in 853 patients) and outcomes after OAC resumption.

Two factors associated with significantly lower odds of hematoma enlargement (volume increase on brain imaging, >33%) were reversal of anticoagulation within 4 hours with an achieved international normalized ratio (INR) <1.3 and systolic blood pressure (SBP) ≤160 mm Hg at 4 hours. Hematoma enlargement occurred in 19.8% of patients with INR <1.3 vs. 41.5% of patients with INR ≥1.3 and in 33.1% of patients with SBP ≤160 mm Hg vs. 52.4% with higher SBP. Patients who achieved both metrics had significantly lower in-hospital mortality (13.5% vs. 20.7%).

Following ICH, 719 patients survived. The 172 survivors who resumed OAC (23.9%) had significantly fewer ischemic complications (5.2% vs. 15.0% in those who did not resume OAC). Hemorrhagic complications did not differ between those who did or did not resume OAC (8.1% and 6.6%).

CITATION(S):

Kuramatsu JB et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015 Feb 24; 313:824.