Dataset Information

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage.

ABSTRACT:

Objective

There is little evidence to guide treatment strategies for intracerebral hemorrhage on vitamin K antagonists (VKA-ICH). Treatments utilized in clinical practice include fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC). Our aim was to compare case fatality with different reversal strategies.

Methods

We pooled individual ICH patient data from 16 stroke registries in 9 countries (n = 10 282), of whom 1,797 (17%) were on VKA. After excluding 250 patients with international normalized ratio < 1.3 and/or missing data required for analysis, we compared all-cause 30-day case fatality using Cox regression.

Results

We included 1,547 patients treated with FFP (n = 377, 24%), PCC (n = 585, 38%), both (n = 131, 9%), or neither (n = 454, 29%). The crude case fatality and adjusted hazard ratio (HR) were highest with no reversal (61.7%, HR = 2.540, 95% confidence interval [CI] = 1.784-3.616, p < 0.001), followed by FFP alone (45.6%, HR = 1.344, 95% CI = 0.934-1.934, p = 0.112), then PCC alone (37.3%, HR = 1.445, 95% CI = 1.014-2.058, p = 0.041), compared to reversal with both FFP and PCC (27.8%, reference). Outcomes with PCC versus FFP were similar (HR = 1.075, 95% CI = 0.874-1.323, p = 0.492); 4-factor PCC (n = 441) was associated with higher case fatality compared to 3-factor PCC (n = 144, HR = 1.441, 95% CI = 1.041-1.995, p = 0.027).

Interpretation

The combination of FFP and PCC might be associated with the lowest case fatality in reversal of VKA-ICH, and FFP may be equivalent to PCC. Randomized controlled trials with functional outcomes are needed to establish the most effective treatment.

SUBMITTER: Parry-Jones AR

PROVIDER: S-EPMC4654243 | biostudies-literature | 2015 Jul

REPOSITORIES: biostudies-literature

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Publications

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage.

Parry-Jones Adrian R AR Di Napoli Mario M Goldstein Joshua N JN Schreuder Floris H B M FH Tetri Sami S Tatlisumak Turgut T Yan Bernard B van Nieuwenhuizen Koen M KM Dequatre-Ponchelle Nelly N Lee-Archer Matthew M Horstmann Solveig S Wilson Duncan D Pomero Fulvio F Masotti Luca L Lerpiniere Christine C Godoy Daniel Agustin DA Cohen Abigail S AS Houben Rik R Al-Shahi Salman Rustam R Pennati Paolo P Fenoglio Luigi L Werring David D Veltkamp Roland R Wood Edith E Dewey Helen M HM Cordonnier Charlotte C Klijn Catharina J M CJ Meligeni Fabrizio F Davis Stephen M SM Huhtakangas Juha J Staals Julie J Rosand Jonathan J Meretoja Atte A

Annals of neurology 20150514 1

<h4>Objective</h4>There is little evidence to guide treatment strategies for intracerebral hemorrhage on vitamin K antagonists (VKA-ICH). Treatments utilized in clinical practice include fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC). Our aim was to compare case fatality with different reversal strategies.<h4>Methods</h4>We pooled individual ICH patient data from 16 stroke registries in 9 countries (n = 10 282), of whom 1,797 (17%) were on VKA. After excluding 250 patients w ...[more]

PMID: 25857223

Similar Datasets

Project description:ImportanceIntracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice.ObjectiveTo evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions.Design, setting, and participantsThis cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023.ExposuresAnticoagulation-associated ICH.Main outcomes and measuresDTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined.ResultsOf 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity.Conclusions and relevanceIn US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.

Dataset Information

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage.

Objective

Methods

Results

Interpretation

Publications

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage.

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