Daniel M Witt1, Nathan P Clark2, Kerri Martinez2, Allison Schroeder3, David Garcia4, Mark A Crowther5, Walter Ageno6, Francesco Dentali6, Xiangyang Ye1, Elaine Hylek7, Thomas Delate8. 1. Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA. 2. Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA. 3. Clinical Pharmacy Department, Veterans Administration, Denver, CO, USA. 4. Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA. 5. Department of Medicine, McMaster University, Hamilton, ON, Canada. 6. Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy. 7. General Internal Medicine Department, Boston University School of Medicine, Boston, MA, USA. 8. Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA. Electronic address: tom.delate@kp.org.
Abstract
BACKGROUND: Whether and when to resume oral anticoagulant therapy for patients who survive warfarin-related intracranial hemorrhage (ICH) remains a dilemma lacking consensus recommendations and high-quality evidence to guide clinical decision making. OBJECTIVE: To determine the incidences of recurrent ICH, thrombosis, and death in relation to resumption or non-resumption of warfarin therapy during the 365 days after incident ICH. METHODS: We conducted a retrospective cohort study of adult patients in an integrated healthcare delivery system who were receiving warfarin therapy at the time of incident (index) ICH between 1/1/2000 and 12/31/2007 and survived to hospital discharge. The primary outcomes were recurrent ICH, thrombosis (stroke, systemic embolism, and venous thromboembolism), and all-cause mortality during the 365 days following index ICH. Patients were assigned to one of two groups defined by warfarin therapy resumption after the index ICH. RESULTS: There were 160 patients discharged from the hospital following warfarin-related index ICH; of these 54 (33.8%) resumed warfarin therapy and 106 (66.2%) did not. Recurrent ICH occurred in a numerically greater, but statistically non-significant, proportion of patients who did not resume warfarin therapy (7.6% vs. 3.7%, p=0.497). Similarly, patients who did not resume warfarin had a three-fold higher (12.3% vs. 3.7%, p=0.092) and approximately two-fold higher (31.1% vs. 18.5%, p=0.089) rates of thrombosis and all-cause mortality, respectively, during follow up. CONCLUSION: Resumption of warfarin therapy following warfarin-associated ICH appeared not to be associated with increased risk of recurrent ICH but trended toward reduced thrombosis and all-cause mortality.
BACKGROUND: Whether and when to resume oral anticoagulant therapy for patients who survive warfarin-related intracranial hemorrhage (ICH) remains a dilemma lacking consensus recommendations and high-quality evidence to guide clinical decision making. OBJECTIVE: To determine the incidences of recurrent ICH, thrombosis, and death in relation to resumption or non-resumption of warfarin therapy during the 365 days after incident ICH. METHODS: We conducted a retrospective cohort study of adult patients in an integrated healthcare delivery system who were receiving warfarin therapy at the time of incident (index) ICH between 1/1/2000 and 12/31/2007 and survived to hospital discharge. The primary outcomes were recurrent ICH, thrombosis (stroke, systemic embolism, and venous thromboembolism), and all-cause mortality during the 365 days following index ICH. Patients were assigned to one of two groups defined by warfarin therapy resumption after the index ICH. RESULTS: There were 160 patients discharged from the hospital following warfarin-related index ICH; of these 54 (33.8%) resumed warfarin therapy and 106 (66.2%) did not. Recurrent ICH occurred in a numerically greater, but statistically non-significant, proportion of patients who did not resume warfarin therapy (7.6% vs. 3.7%, p=0.497). Similarly, patients who did not resume warfarin had a three-fold higher (12.3% vs. 3.7%, p=0.092) and approximately two-fold higher (31.1% vs. 18.5%, p=0.089) rates of thrombosis and all-cause mortality, respectively, during follow up. CONCLUSION: Resumption of warfarin therapy following warfarin-associated ICH appeared not to be associated with increased risk of recurrent ICH but trended toward reduced thrombosis and all-cause mortality.
Authors: Daniel M Witt; Robby Nieuwlaat; Nathan P Clark; Jack Ansell; Anne Holbrook; Jane Skov; Nadine Shehab; Juliet Mock; Tarra Myers; Francesco Dentali; Mark A Crowther; Arnav Agarwal; Meha Bhatt; Rasha Khatib; John J Riva; Yuan Zhang; Gordon Guyatt Journal: Blood Adv Date: 2018-11-27
Authors: Zien Zhou; Jie Yu; Cheryl Carcel; Candice Delcourt; Jiehui Shan; Richard I Lindley; Bruce Neal; Craig S Anderson; Maree L Hackett Journal: BMJ Open Date: 2018-05-14 Impact factor: 2.692