Higher baseline international normalized ratio value correlates with higher mortality in intracerebral hemorrhage during warfarin use.
OBJECTIVE
Intracerebral hemorrhage (ICH) is the most feared complication of oral anticoagulation (OAC). Our aim was to investigate the impact of the international normalized ratio (INR) level on mortality in OAC-associated ICH compared with non-OAC-associated ICH.


METHODS
A retrospective chart review of consecutive ICH patients treated at the Helsinki University Central Hospital from January 2005 to March 2010 (n = 1013) was performed. An ICH was considered to be OAC-associated if the patient was on warfarin at ICH onset. The association of INR with 3-month mortality was adjusted in a multivariable logistic regression model for factors influencing the crude odds ratios (ORs) in bivariable logistic regression by more than 5%.


RESULTS
One in eight ICHs was OAC-associated (n = 132). Of these, 50% had therapeutic INR (2.0-3.0), 7% had INR <2.0 and 43% had high INR (>3.0) on admission. Patients on OAC were older (median 76 vs. 66 years; P < 0.001) with more severe symptoms (median National Institutes of Health Stroke Scale 14 vs. 10; P < 0.001) and larger hematomas (median 11.4 vs. 9.7 ml; P < 0.001) on admission than patients not on OAC. After adjustment for confounders, 3-month mortality in the whole cohort was associated with higher baseline INR (OR 1.06; CI 1.03-1.09 per 0.1 increment). Mortality was higher with both therapeutic (51% at 3 months; OR 3.59; CI 1.50-8.60) and high (61%; OR 5.26; CI 1.94-14.27) INR values compared with non-OAC-associated ICH (29%).


CONCLUSIONS
Patients with OAC-associated ICH had more severe strokes and higher mortality compared with patients with ICH not related to OAC. Higher baseline INR was associated with increased 3-month mortality.
Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
S
S
Curtze
D
D
Strbian
A
A
Meretoja
J
J
Putaala
H
H
Eriksson
E
E
Haapaniemi
S
S
Mustanoja
T
T
Sairanen
J
J
Satopää
H
H
Silvennoinen
M
M
Niemelä
M
M
Kaste
T
T
Tatlisumak
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D002391:Catchment Area, Health; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000401:mortality*; D005260:Female; D005387:Finland; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D012016:Reference Values; D012189:Retrospective Studies; D014859:Warfarin / Q000009:adverse effects*
D000925:Anticoagulants; D014859:Warfarin
anticoagulation; hematoma growth; intracerebral hemorrhage; mortality; prognosis; warfarin