Oral Anticoagulants Do Not Pose Additional Intracerebral Hemorrhage Risk

Internal Medicine World Report, April 2015,

Patients resuming oral anticoagulants do not show greater risk of recurrent intracerebral hemorrhage, according to a study published in JAMA.

Research published in JAMA may assist the management of oral anticoagulant (OAC) related bleeding with in the brain (intracerebral hemorrhage, ICH). The authors wrote there is a significant lack of data on how to treat ICH linked to OAC, and aimed to change that.

Researchers from Germany retrospectively analyzed 19 German tertiary care centers between 2006 and 2012 in order to assess the association of anticoagulation reversal and BP with hematoma enlargement and the effects of OAC resumption. The study included 1,176 patients for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption. The researchers analyzed the patients’ reversal of anticoagulation during the acute phase, systolic BP at 4 hours, and re-initiation of OAC for long-term treatment.

Approximately one-third (307 of 853) of the patients experienced hemorrhage enlargement, the researchers discovered. Decreased rates of hematoma enlargement were linked to the reversal of INR levels < 1.3 within 4 hours after admission and systolic BP < 160 mm Hg at 4 hours. The researchers further wrote that both INR reversal < 1.3 within 4 hours and systolic BP < 160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement not achieving these values and lower rates of in hospital mortality. In about a quarter of the patients (172 of 719), the researchers observed the resuming of OAC, which showed fewer ischemic complications and not statistically different hemorrhagic complications. After a propensity matched survival analysis in atrial fibrillation patients who restarted OAC, the researchers saw decreased hazard ratios of 0.258 for long term mortality. The researchers noted that for 3 quarters of patients (786 of 1,083), functional long-term outcome was unfavorable.

“The study represents the largest cohort of patients with OAC ICH to date and reports 2 clinically valuable associations,” the authors summarized. “First, rates of hematoma enlargement were decreased in patients with INR values reversed below 1.3 within 4 hours of admission and systolic BP of less than 160 mm Hg at 4 hours. Second, rates of ischemic events were decreased among patients who restarted OAC without increased rates of bleeding complications. These retrospective findings require replication and assessment in prospective studies.”

The researchers also discussed the strengths of their study, which included a large sample size. One drawback they noted, however, was the retrospective nature of the study — which had an impact on what can be interpreted from the data. Nonetheless, these new findings support prior studies that indicate patients restarting OAC do not show greater risk for recurrent ICH.