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J Neurol. 2019 Dec 17. doi: 10.1007/s00415-019-09678-2. [Epub ahead of print]

Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation.

Author information

1
Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA. vlioutas@bidmc.harvard.edu.
2
Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
3
Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada.
4
Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany.
5
Department of Neurology, Geisinger Medical Center, Danville, PA, USA.
6
Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
7
Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
8
Department of Neurology, Allegheny Health Network, Pittsburgh, PA, USA.
9
Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
10
Second Department of Neurology, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
11
Department of Neurology, Essentia Health-Duluth Clinic, Duluth, MN, USA.
12
Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA.
13
Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
14
Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
15
Laboratory of Haematology and Blood Bank Unit (A.T.), School of Medicine, "Attikon" Hospital, National and Kapodistrian University of Athens, Athens, Greece.
16
Second Department of Neurosurgery, School of Medicine, "Attikon University Hospital", National and Kapodistrian University of Athens, Athens, Greece.
17
Department of Child and Adolescent Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
18
Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
19
Department of Neurology, School of Medicine, University of Crete, Crete, Greece.
20
Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.

Abstract

BACKGROUND:

Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification.

METHODS:

We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a "Favorable" indication for anticoagulation; if negative, "Unfavorable".

RESULTS:

We enrolled 357 patients [59% men, median age 76 (68-82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66-80) vs 78 (73-84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3-4) vs 5(4-6), p < 0.001]. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%, p = 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease.

CONCLUSIONS:

In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk.

KEYWORDS:

Anticoagulants; Atrial fibrillation; Intracerebral hemorrhage; Risk assessment

PMID:
31848737
DOI:
10.1007/s00415-019-09678-2

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