Elsevier

Thrombosis Research

Volume 108, Issue 1, 1 October 2002, Pages 31-36
Thrombosis Research

Regular Article
Oral-anticoagulant-related intracerebral hemorrhage

https://doi.org/10.1016/S0049-3848(02)00398-5Get rights and content

Abstract

Background: The characteristics, management and outcomes of patients who suffer intracerebral hemorrhage (ICH) while taking oral anticoagulants (OAC) are relatively unreported. Design: Retrospective cohort study of consecutive cases with ICH associated with OAC. Setting: A university-affiliated tertiary care hospital in Ontario, Canada. Patients/participants: 368 charts of individuals with a discharge diagnosis of ICH (ICD-9 code 431) between January 1993 and May 1998 were reviewed. Main results: 20 (5.4%, 95% confidence interval (CI): 3.1–7.7%) of the 368 ICHs occurred in people taking OAC. The median age of patients on OAC was 74 years (S.D.±9.8), and 70% (95% CI: 49–91%) were female. The median INR at presentation was 3.4 (intraquartile (IQR) range 2.2–4.4). Nine of 20 (45%) patients had INR values which exceeded the target range. The case fatality rate was 45% (95% CI: 23–67%). Approximately 2.8 years after the initial ICH, 9 of the 11 patients who survived the initial ICH were still alive, and 6 had restarted OAC. Conclusions: ICH is a serious complication in patients taking OAC, and the case-fatality rate is high. Given the increasing use of OAC in patients with cardiovascular disease, the relative benefits and risks of this therapy must be weighed carefully.

Introduction

Intracerebral hemorrhage (ICH) is a serious and often fatal complication of long-term oral anticoagulants (OAC). Retrospective reviews report the risk of ICH among patients on warfarin is increased by 7 to 10 times [1], [2], [3], [4]. A recent meta-analysis of three prospective randomized trials reported that 1.1% of patients taking long-term OAC compared to only 0.1% of patients not taking OAC suffered an ICH (odds ratio=5.1, 95% confidence interval (CI): 2.6–10.3) [5]. The characteristics and management of patients who suffer ICH and require anticoagulation to prevent other life-threatening complications are relatively unreported [6], [7], [8]. Little research has been done into establishing risk factors that might predict which patients are likely to sustain a severely disabling ICH. Current guidelines suggest that individuals with anticoagulant-related ICH receive vitamin K and factor replacement as standard therapy for the reversal of anticoagulation [9]. Apart from immediate treatment of these patients, the long-term management and prognosis is relatively underreported [6], [7], [8]. To address some of these issues, we conducted a review of charts at a university-associated tertiary care hospital to describe patients who suffered ICH while receiving OAC, their management, and prognosis.

Section snippets

Methods

A retrospective chart review of consecutive patients who suffered an ICH between January 1993 and May 1998 was conducted. All charts in which the discharge diagnosis recorded was an ICH (ICD-9 code 431) were retrieved from medical records. A standardized data collection form was used to abstract data from each chart (see Appendix A). Continuous variables are presented as medians and interquartile ranges (IQR) where appropriate and categorical data are displayed as percentages. The exact 95%

Results

In total, 368 charts were reviewed and 20 (5.4%) patients suffered an ICH while receiving OAC. Briefly, the most common cause of intracerebral hemorrhage was hypertension (n=80% of 368). The other causes are listed in Table 1. The median age of patients who suffered an ICH while receiving OAC was 74 years (IQR 65.5–77.2) and 70% (14/20) of the patients were female. The reasons the ICH patients were taking OACs are listed in Table 2. In all but one case, the INR target was 2.0 to 3.0; and in one

Discussion

In our study of 368 patients with ICH admitted over about 5 years, approximately 5.4% were taking OACs; the case-fatality rate was almost 50%. Forty-five percent of the patients with OAC-ICH had INR values above the target range, and 42% were taking aspirin concomitantly, two factors known to increase the risk of bleeding associated with oral anticoagulants.

The management of patients with OAC-ICH is variable reflecting the lack of published guidelines [6], [7], [8]. The decision regarding when

Conclusion

Intracerebral hemorrhage is an important complication of oral anticoagulant therapy. Factors that appear to increase the risk of OAC-ICH include old age, use of aspirin, and INR values above the target intensity. Given the high case-fatality rate associated with ICH, careful monitoring of elderly patients on OAC is important. The severity of this issue is compounded by the fact that close to one-half of the individuals with OAC-ICH died as a result of their bleeds. However, of those who

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    The incidence of vitamin K antagonists (VKAs)-associated major bleeding ranges between 2% and 5% per year [7] and that of intracranial hemorrhage (ICH) between 0.2% and 0.4% per year [8]. The case-fatality rate of VKA-associated major bleeding varies between 8% and 10% [9] and that of VKA-associated ICH between 45% and 50% [10]. These incidences vary due to differences in the definitions of major bleeding, study designs and patient populations [11,12].

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