Anticoagulant Reversal, Blood Pressure Levels, and Anticoagulant Resumption in Patients With Anticoagulation-Related Intracerebral Hemorrhage

被引：428

作者：

Kuramatsu, Joji B. ^{[1
]}

Gerner, Stefan T. ^{[1
]}

Schellinger, Peter D. ^{[2
]}

Glahn, Joerg ^{[2
]}

Endres, Matthias ^{[3
,4
,5
,6
]}

Sobesky, Jan ^{[3
]}

Flechsenhar, Julia ^{[3
]}

Neugebauer, Hermann ^{[3
,7
]}

Juettler, Eric ^{[3
,7
]}

Grau, Armin ^{[8
]}

Palm, Frederick ^{[8
]}

Roether, Joachim ^{[9
]}

Michels, Peter ^{[9
]}

Hamann, Gerhard F. ^{[10
]}

Huewel, Joachim ^{[10
]}

Hagemann, Georg ^{[11
]}

Barber, Beatrice ^{[11
]}

Terborg, Christoph ^{[12
]}

Trostdorf, Frank ^{[12
]}

Baezner, Hansjoerg ^{[13
]}

Roth, Aletta ^{[13
]}

Woehrle, Johannes ^{[14
]}

Keller, Moritz ^{[14
]}

Schwarz, Michael ^{[15
]}

Reimann, Gernot ^{[15
]}

Volkmann, Jens ^{[16
]}

Muellges, Wolfgang ^{[16
]}

Kraft, Peter ^{[16
,17
]}

Classen, Joseph ^{[18
]}

Hobohm, Carsten ^{[18
]}

Horn, Markus ^{[19
]}

Milewski, Angelika ^{[19
]}

Reichmann, Heinz ^{[20
]}

Schneider, Hauke ^{[20
]}

Schimmel, Eik ^{[20
]}

Fink, Gereon R. ^{[21
]}

Dohmen, Christian ^{[21
]}

Stetefeld, Henning ^{[21
]}

Witte, Otto ^{[22
]}

Guenther, Albrecht ^{[22
]}

Neumann-Haefelin, Tobias ^{[23
]}

Racs, Andras E.

Nueckel, Martin

Erbguth, Frank ^{[23
]}

Kloska, Stephan P. ^{[24
]}

Doerfler, Arnd ^{[24
]}

Koehrmann, Martin ^{[1
]}

Schwab, Stefan ^{[1
]}

Huttner, Hagen B. ^{[1
]}

机构：

[1] Univ Erlangen Nurnberg, Dept Neurol, D-91054 Erlangen, Germany

[2] Johannes Wesling Klinikum Minden, Community Hosp, Dept Neurol & Neurogeriatry, Minden, Germany

[3] Charite, Dept Neurol, D-13353 Berlin, Germany

[4] Ctr Stroke Res Berlin, Berlin, Germany

[5] German Ctr Cardiovasc Res DZHK, Berlin, Germany

[6] Charite, German Ctr Neurodegenerat Dis DZNE, Berlin, Germany

[7] Univ Ulm, Dept Neurol, D-89069 Ulm, Germany

[8] Community Hosp Klinikum Stadt Ludwigshafen Rhein, Dept Neurol, Ludwigshafen, Germany

[9] Community Hosp Asklepios Klin Hamburg Altona, Dept Neurol, Hamburg, Germany

[10] Community Hosp Dr Horst Schmidt Klinikum Wiesbade, Dept Neurol, Wiesbaden, Germany

[11] Community Hosp Helios Klinikum Berlin Buch, Dept Neurol, Berlin, Germany

[12] Community Hosp Asklepios Klin St Georg, Dept Neurol, Hamburg, Germany

[13] Community Hosp Klinikum Stuttgart, Dept Neurol, Stuttgart, Germany

[14] Community Hosp Klinikum Koblenz, Dept Neurol, Koblenz, Germany

[15] Community Hosp Klinikum Dortmund, Dept Neurol, Dortmund, Germany

[16] Univ Wurzburg, Dept Neurol, D-97070 Wurzburg, Germany

[17] Univ Wurzburg, Comprehens Heart Failure Ctr, Inst Clin Epidemiol & Biometry, D-97070 Wurzburg, Germany

[18] Univ Leipzig, Dept Neurol, D-04109 Leipzig, Germany

[19] Community Hosp Bad Hersfeld, Dept Neurol, Bad Hersfeld, Germany

[20] Univ Dresden, Dept Neurol, Dresden, Germany

[21] Univ Cologne, Dept Neurol, D-50931 Cologne, Germany

[22] Univ Jena, Dept Neurol, Jena, Germany

[23] Community Hosp Fulda, Dept Neurol, Fulda, Germany

[24] Univ Erlangen Nurnberg, Dept Neuroradiol, D-91054 Erlangen, Germany

来源：

JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2015年 / 313卷 / 08期

关键词：

ATRIAL-FIBRILLATION; HEMATOMA EXPANSION; VITAMIN-K; WARFARIN; STROKE; RISK; MANAGEMENT; VALIDATION; GUIDELINES; INTENSITY;

D O I：

10.1001/jama.2015.0846

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

IMPORTANCE Although use of oral anticoagulants (OACs) is increasing, there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage (ICH). OBJECTIVE To assess the association of anticoagulation reversal and blood pressure (BP) with hematoma enlargement and the effects of OAC resumption. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at 19 German tertiary care centers (2006-2012) including 1176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption. EXPOSURES Reversal of anticoagulation during acute phase, systolic BP at 4 hours, and reinitiation of OAC for long-term treatment. MAIN OUTCOMES AND MEASURES Frequency of hematoma enlargement in relation to international normalized ratio (INR) and BP. Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption. Factors associated with favorable (modified Rankin Scale score, 0-3) vs unfavorable functional outcome. RESULTS Hemorrhage enlargement occurred in 307 of 853 patients (36.0%). Reduced rates of hematoma enlargement were associated with reversal of INR levels <1.3 within 4 hours after admission (43/217 [19.8%]) vs INR of >= 1.3 (264/636 [41.5%]; P < .001) and systolic BP <160 mm Hg at 4 hours (167/504 [33.1%]) vs >= 160 mm Hg (98/187 [52.4%]; P < .001). The combination of INR reversal < 1.3 within 4 hours and systolic BP of < 160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement (35/193 [18.1%] vs 220/498 [44.2%] not achieving these values; OR, 0.28; 95% CI, 0.19-0.42; P < .001) and lower rates of in-hospital mortality (26/193 [13.5%] vs 103/498 [20.7%]; OR, 0.60; 95% CI, 0.37-0.95; P = .03). OAC was resumed in 172 of 719 survivors (23.9%). OAC resumption showed fewer ischemic complications (OAC: 9/172 [5.2%] vs no OAC: 82/547 [15.0%]; P < .001) and not significantly different hemorrhagic complications (OAC: 14/172 [8.1%] vs no OAC: 36/547 [6.6%]; P = .48). Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 (95% CI, 0.125-0.534; P < .001) for long-term mortality. Functional long-term outcome was unfavorable in 786 of 1083 patients (72.6%). CONCLUSIONS AND RELEVANCE Among patients with OAC-associated ICH, reversal of INR < 1.3 within 4 hours and systolic BP < 160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement, and resumption of OAC therapy was associated with lower risk of ischemic events. These findings require replication and assessment in prospective studies.

引用

页码：824 / 836

页数：13

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