Fahad AlKherayf1, Yan Xu2, Harrison Westwick3, Ioana Doina Moldovan4, Philip S Wells5. 1. Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada. Electronic address: falkherayf@toh.ca. 2. School of Medicine, Queen's University, Kingston, Canada; Division of Hematology, Department of Medicine, Ottawa, Canada. 3. Division of Neurosurgery, Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada. 4. Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Canada. 5. Division of Hematology, Department of Medicine, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada.
Abstract
BACKGROUND: While oral anticoagulation (OAC) is universally indicated for patients with mechanical heart valves (MHVs), OAC resumption following anticoagulant-associated intracerebral hemorrhage (ICH) is an area of uncertainty. We sought to determine the practice preferences of North American neurosurgeons and thrombosis experts on optimal timing of OAC re-initiation. METHODS: A cross-sectional survey was disseminated to North American members of the American Association of Neurological Surgeons and the International Society for Thrombosis and Haemostasis. Demographic factors, as well as a clinical scenario with 14 modifiable clinical risk factors were included in the survey. RESULTS: 504 physicians completed our survey (response rate 34.3%). Majority of participants were affiliated with academic centres, and managed≤10 ICH patients with MHV per year. There was wide distribution in response in optimal timing for OAC resumption following an ICH: 59% and 60% preferred to re-start OAC between 3 and 14 days following the hemorrhagic event (median of 6-7 days). Smaller hemorrhages (<30cm2). CHADS2 score ≥2, concomitant venous thromboembolism, mitral valve prosthesis, caged-ball valves and multiple valves prompted earlier OAC resumption. CONCLUSION: Wide variation in the current practice of neurosurgeons and thrombosis specialists exist when they encounter patients with ICH and MHV, though decisions were influenced by patient- and valve-related factors. As our observed variation likely reflects the immense gap in current evidence, prospective randomized trials in this population are therefore urgently needed.
BACKGROUND: While oral anticoagulation (OAC) is universally indicated for patients with mechanical heart valves (MHVs), OAC resumption following anticoagulant-associated intracerebral hemorrhage (ICH) is an area of uncertainty. We sought to determine the practice preferences of North American neurosurgeons and thrombosis experts on optimal timing of OAC re-initiation. METHODS: A cross-sectional survey was disseminated to North American members of the American Association of Neurological Surgeons and the International Society for Thrombosis and Haemostasis. Demographic factors, as well as a clinical scenario with 14 modifiable clinical risk factors were included in the survey. RESULTS: 504 physicians completed our survey (response rate 34.3%). Majority of participants were affiliated with academic centres, and managed≤10 ICHpatients with MHV per year. There was wide distribution in response in optimal timing for OAC resumption following an ICH: 59% and 60% preferred to re-start OAC between 3 and 14 days following the hemorrhagic event (median of 6-7 days). Smaller hemorrhages (<30cm2). CHADS2 score ≥2, concomitant venous thromboembolism, mitral valve prosthesis, caged-ball valves and multiple valves prompted earlier OAC resumption. CONCLUSION: Wide variation in the current practice of neurosurgeons and thrombosis specialists exist when they encounter patients with ICH and MHV, though decisions were influenced by patient- and valve-related factors. As our observed variation likely reflects the immense gap in current evidence, prospective randomized trials in this population are therefore urgently needed.
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