Fahad AlKherayf1, Yan Xu2, Esteban Gandara3, Harrison Westwick4, Ioana Doina Moldovan5, Philip S Wells6. 1. Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. Electronic address: falkherayf@toh.ca. 2. School of Medicine, Queen's University, Kingston, Canada. 3. Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada. 4. Division of Neurosurgery, Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada. 5. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. 6. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.
Abstract
BACKGROUND: While evidence supports resumption of vitamin K antagonists (VKAs) among mechanical heart valve (MHV) patients presenting with anticoagulant-associated intracranial hemorrhage (ICH), ideal timing of resumption is uncertain. OBJECTIVE: To determine the optimal timing of VKA re-initiation and its associated clinical outcomes. METHODS: We performed a systematic review and a meta-analysis of studies published from January 1950 to August 2015. We extracted data on the location of initial ICH, use of cranial surgery, presence of atrial fibrillation, MHV type and position, number of MHVs, and timing of VKA resumption. Outcomes including valve thrombosis, thromboembolic events or ICH recurrence were recorded. Meta-regression analysis was conducting with controlling for covariates. We calculated absolute risks, and assessed the effect of anticoagulant resumption timing on ICH recurrence. RESULTS: 23 case-series and case-reports were identified. Overall ICH recurrence was 13% (95% confidence interval [CI], 7%-25%), while valve thrombosis and ischemic strokes occurred at 7% (95% CI, 3%-17%) and 12% (95% CI, 5%-23%) respectively. A trend towards lower ICH recurrence was observed with delayed VKA resumption (slope estimate -0.2154, p=0.10). Recurrence rate ranged from 50% with VKA resumption at 3days to 0% with resumption at 16days. CONCLUSION: Among patients with MHV, there is inadequate data to suggest an optimal timing of VKA re-initiation following an ICH, though delayed restart appears to be protective against recurrence but is associated with higher risk of thrombosis. Our analysis suggests 4-7days might be an ideal time with least risk of thrombosis or ICH recurrence.
BACKGROUND: While evidence supports resumption of vitamin K antagonists (VKAs) among mechanical heart valve (MHV) patients presenting with anticoagulant-associated intracranial hemorrhage (ICH), ideal timing of resumption is uncertain. OBJECTIVE: To determine the optimal timing of VKA re-initiation and its associated clinical outcomes. METHODS: We performed a systematic review and a meta-analysis of studies published from January 1950 to August 2015. We extracted data on the location of initial ICH, use of cranial surgery, presence of atrial fibrillation, MHV type and position, number of MHVs, and timing of VKA resumption. Outcomes including valve thrombosis, thromboembolic events or ICH recurrence were recorded. Meta-regression analysis was conducting with controlling for covariates. We calculated absolute risks, and assessed the effect of anticoagulant resumption timing on ICH recurrence. RESULTS: 23 case-series and case-reports were identified. Overall ICH recurrence was 13% (95% confidence interval [CI], 7%-25%), while valve thrombosis and ischemic strokes occurred at 7% (95% CI, 3%-17%) and 12% (95% CI, 5%-23%) respectively. A trend towards lower ICH recurrence was observed with delayed VKA resumption (slope estimate -0.2154, p=0.10). Recurrence rate ranged from 50% with VKA resumption at 3days to 0% with resumption at 16days. CONCLUSION: Among patients with MHV, there is inadequate data to suggest an optimal timing of VKA re-initiation following an ICH, though delayed restart appears to be protective against recurrence but is associated with higher risk of thrombosis. Our analysis suggests 4-7days might be an ideal time with least risk of thrombosis or ICH recurrence.
Authors: Joji B Kuramatsu; Jochen A Sembill; Stefan T Gerner; Maximilian I Sprügel; Manuel Hagen; Sebastian S Roeder; Matthias Endres; Karl Georg Haeusler; Jan Sobesky; Johannes Schurig; Sarah Zweynert; Miriam Bauer; Peter Vajkoczy; Peter A Ringleb; Jan Purrucker; Timolaos Rizos; Jens Volkmann; Wolfgang Müllges; Peter Kraft; Anna-Lena Schubert; Frank Erbguth; Martin Nueckel; Peter D Schellinger; Jörg Glahn; Ulrich J Knappe; Gereon R Fink; Christian Dohmen; Henning Stetefeld; Anna Lena Fisse; Jens Minnerup; Georg Hagemann; Florian Rakers; Heinz Reichmann; Hauke Schneider; Sigrid Wöpking; Albert Christian Ludolph; Sebastian Stösser; Hermann Neugebauer; Joachim Röther; Peter Michels; Michael Schwarz; Gernot Reimann; Hansjörg Bäzner; Henning Schwert; Joseph Claßen; Dominik Michalski; Armin Grau; Frederick Palm; Christian Urbanek; Johannes C Wöhrle; Fahid Alshammari; Markus Horn; Dirk Bahner; Otto W Witte; Albrecht Günther; Gerhard F Hamann; Hannes Lücking; Arnd Dörfler; Stephan Achenbach; Stefan Schwab; Hagen B Huttner Journal: Eur Heart J Date: 2018-05-14 Impact factor: 29.983
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