Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?
OBJECTIVE
To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.


METHODS
Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.


RESULTS
The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome.


CONCLUSIONS
Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.
Stead
Latha G
LG
Department of Emergency Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA. latha_stead@urmc.rochester.edu
Jain
Anunaya
A
Bellolio
M Fernanda
MF
Odufuye
Adetolu O
AO
Dhillon
Ravneet K
RK
Manivannan
Veena
V
Gilmore
Rachel M
RM
Rabinstein
Alejandro A
AA
Chandra
Raghav
R
Serrano
Luis A
LA
Yerragondu
Neeraja
N
Palamari
Balavani
B
Decker
Wyatt W
WW
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D001921:Brain / Q000473:pathology; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D015331:Cohort Studies; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D011379:Prognosis; D016896:Treatment Outcome
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors