Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage

Kuramatsu J, Gerner S, Schellinger PD, Glahn J, Endres M, Sobesky J, Flechsenhar J, Neugebauer H, Juettler E, Grau A, Palm F, Roether J, Michels P, Hamann GF, Huewel J, Hagemann G, Barber B, Terborg C, Trostdorf F, Baezner H, Roth A, Woehrle J, Keller M, Schwarz M, Reimann G, Volkmann J, Muellges W, Kraft P, Classen J, Hobohm C, Horn M, Milewski A, Reichmann H, Schneider H, Schimmel E, Fink GR, Dohmen C, Stetefeld H, Witte O, Guenther A, Neumann-Haefelin T, Racs AE, Nueckel M, Erbguth F, Kloska S, Dörfler A, Köhrmann M, Schwab S, Huttner H (2015)

Publication Type: Journal article

Publication year: 2015

Journal

Book Volume: 313

Pages Range: 824-36

Journal Issue: 8

DOI: 10.1001/jama.2015.0846

Abstract

Although use of oral anticoagulants (OACs) is increasing, there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage (ICH).To assess the association of anticoagulation reversal and blood pressure (BP) with hematoma enlargement and the effects of OAC resumption.Retrospective cohort study at 19 German tertiary care centers (2006-2012) including 1176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption.Reversal of anticoagulation during acute phase, systolic BP at 4 hours, and reinitiation of OAC for long-term treatment.Frequency of hematoma enlargement in relation to international normalized ratio (INR) and BP. Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption. Factors associated with favorable (modified Rankin Scale score, 0-3) vs unfavorable functional outcome.Hemorrhage enlargement occurred in 307 of 853 patients (36.0%). Reduced rates of hematoma enlargement were associated with reversal of INR levels <1.3 within 4 hours after admission (43/217 [19.8%]) vs INR of >=1.3 (264/636 [41.5%]; P < .001) and systolic BP <160 mm Hg at 4 hours (167/504 [33.1%]) vs >=160 mm Hg (98/187 [52.4%]; P < .001). The combination of INR reversal <1.3 within 4 hours and systolic BP of <160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement (35/193 [18.1%] vs 220/498 [44.2%] not achieving these values; OR, 0.28; 95% CI, 0.19-0.42; P < .001) and lower rates of in-hospital mortality (26/193 [13.5%] vs 103/498 [20.7%]; OR, 0.60; 95% CI, 0.37-0.95; P = .03). OAC was resumed in 172 of 719 survivors (23.9%). OAC resumption showed fewer ischemic complications (OAC: 9/172 [5.2%] vs no OAC: 82/547 [15.0%]; P < .001) and not significantly different hemorrhagic complications (OAC: 14/172 [8.1%] vs no OAC: 36/547 [6.6%]; P = .48). Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 (95% CI, 0.125-0.534; P < .001) for long-term mortality. Functional long-term outcome was unfavorable in 786 of 1083 patients (72.6%).Among patients with OAC-associated ICH, reversal of INR <1.3 within 4 hours and systolic BP <160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement, and resumption of OAC therapy was associated with lower risk of ischemic events. These findings require replication and assessment in prospective studies.clinicaltrials.gov Identifier: NCT01829581.

Authors with CRIS profile

Involved external institutions

Klinikum Fulda Germany (DE) Johannes Wesling Klinikum Minden Germany (DE) Charité - Universitätsmedizin Berlin Germany (DE) Klinikum der Stadt Ludwigshafen am Rhein gGmbH Germany (DE) Asklepios Klinik Altona Germany (DE) Horst-Schmidt-Kliniken Germany (DE) HELIOS Kliniken Germany (DE) Asklepios Kliniken Germany (DE) Klinikum Stuttgart Germany (DE) Gemeinschaftsklinikum Mittelrhein Germany (DE) Klinikum Dortmund Germany (DE) Julius-Maximilians-Universität Würzburg Germany (DE) Universität Leipzig Germany (DE) Klinikum Bad Hersfeld GmbH Germany (DE) Technische Universität Dresden Germany (DE) Universität zu Köln Germany (DE) Friedrich-Schiller-Universität Jena Germany (DE)

How to cite

APA:

Kuramatsu, J., Gerner, S., Schellinger, P.D., Glahn, J., Endres, M., Sobesky, J.,... Huttner, H. (2015). Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. Journal of the American Medical Association, 313(8), 824-36. https://doi.org/10.1001/jama.2015.0846

MLA:

Kuramatsu, Joji, et al. "Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage." Journal of the American Medical Association 313.8 (2015): 824-36.

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