Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Journal article

Publication Details

Author(s): Kuramatsu JB, Sembill J, Gerner S, Sprügel M, Hagen M, Röder S, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Muellges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Woepking S, Ludolph AC, Stoesser S, Neugebauer H, Roether J, Michels P, Schwarz M, Reimann G, Baezner H, Schwert H, Classen J, Michalski D, Grau A, Palm F, Urbanek C, Woehrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Guenther A, Hamann GF, Lücking H, Dörfler A, Achenbach S, Schwab S, Huttner H
Journal: European Heart Journal
Publication year: 2018
Volume: 39
Journal issue: 19
Pages range: 1709-1723
ISSN: 0195-668X
eISSN: 1522-9645


Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH.
Methods and results We pooled individual patient- data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67-35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33-21.37; P < 0.01). The hazard for the composite-balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10-5.70; P = 0.03).
Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing-between least risks for thromboembolic and haemorrhagic complications-provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk.

FAU Authors / FAU Editors

Achenbach, Stephan Prof. Dr. med.
Medizinische Klinik 2 - Kardiologie, Angiologie
Dörfler, Arnd Prof. Dr.
Neuroradiologische Abteilung im Radiologischen Institut
Gerner, Stefan
Medizinische Fakultät
Hagen, Manuel Dr. med.
Neurologische Klinik
Huttner, Hagen Prof. Dr.
Medizinische Fakultät
Lücking, Hannes Dr. med.
Neuroradiologische Abteilung im Radiologischen Institut
Röder, Sebastian Dr. med.
Neurologische Klinik
Schwab, Stefan Prof. Dr.
Lehrstuhl für Neurologie
Sembill, Jochen
Medizinische Fakultät
Sprügel, Maximilian
Neurologische Klinik

External institutions with authors

Asklepios Klinik Altona
Bezirkskrankenhaus Günzburg
Charité - Universitätsmedizin Berlin
Friedrich-Schiller-Universität Jena
Gemeinschaftsklinikum Mittelrhein
HELIOS Kliniken
Humboldt-Universität zu Berlin
Julius-Maximilians-Universität Würzburg
Klinikum Bad Hersfeld GmbH
Klinikum der Stadt Ludwigshafen am Rhein gGmbH
Klinikum Dortmund
Klinikum Nürnberg
Klinikum Stuttgart
Ruhr-Universität Bochum (RUB)
Technische Universität Dresden
Universität Köln
Universität Leipzig
Universitätsklinikum Heidelberg
Universität Ulm
Westfälische Wilhelms-Universität (WWU) Münster

How to cite

Kuramatsu, J.B., Sembill, J., Gerner, S., Sprügel, M., Hagen, M., Röder, S.,... Huttner, H. (2018). Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves. European Heart Journal, 39(19), 1709-1723.

Kuramatsu, Joji B., et al. "Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves." European Heart Journal 39.19 (2018): 1709-1723.


Last updated on 2019-19-09 at 07:11