Management of therapeutic anticoagulation in patients with intracerebral haemorrhage andmechanical heart valves

被引：74

作者：

Kuramatsu, Joji B. ^{[1
]}

Sembill, Jochen A. ^{[1
]}

Gerner, Stefan T. ^{[1
]}

Spruegel, Maximilian I. ^{[1
]}

Hagen, Manuel ^{[1
]}

Roeder, Sebastian S. ^{[1
]}

Endres, Matthias ^{[2
,3
,4
,5
,6
]}

Haeusler, Karl Georg ^{[2
,3
,4
]}

Sobesky, Jan ^{[2
,3
,4
]}

Schurig, Johannes ^{[4
]}

Zweynert, Sarah ^{[2
,3
]}

Bauer, Miriam ^{[4
]}

Vajkoczy, Peter ^{[7
]}

Ringleb, Peter A. ^{[8
]}

Purrucker, Jan ^{[8
]}

Rizos, Timolaos ^{[8
]}

Volkmann, Jens ^{[9
]}

Muellges, Wolfgang ^{[9
]}

Kraft, Peter ^{[9
]}

Schubert, Anna-Lena ^{[9
]}

Erbguth, Frank ^{[10
]}

Nueckel, Martin ^{[10
]}

Schellinger, Peter D. ^{[11
]}

Glahn, Joerg ^{[11
]}

Knappe, Ulrich J. ^{[12
]}

Fink, Gereon R. ^{[13
]}

Dohmen, Christian ^{[13
]}

Stetefeld, Henning ^{[13
]}

Fisse, Anna Lena ^{[14
]}

Minnerup, Jens ^{[14
]}

Hagemann, Georg ^{[15
]}

Rakers, Florian ^{[15
]}

Reichmann, Heinz ^{[16
]}

Schneider, Hauke ^{[16
]}

Woepking, Sigrid ^{[16
]}

Ludolph, Albert Christian ^{[17
]}

Stoesser, Sebastian ^{[17
]}

Neugebauer, Hermann ^{[17
]}

Roether, Joachim ^{[18
]}

Michels, Peter ^{[18
]}

Schwarz, Michael ^{[19
]}

Reimann, Gernot ^{[19
]}

Baezner, Hansjoerg ^{[20
]}

Schwert, Henning ^{[20
]}

Classen, Joseph ^{[21
]}

Michalski, Dominik ^{[21
]}

Grau, Armin ^{[22
]}

Palm, Frederick ^{[22
]}

Urbanek, Christian ^{[22
]}

Woehrle, Johannes C. ^{[23
]}

机构：

[1] Univ Erlangen Nurnberg, Dept Neurol, Schwabachanlage 6, D-91054 Erlangen, Germany

[2] Humboldt Univ, Freie Univ Berlin, Charite Univ Med Berlin, Dept Neurol, Charite Pl 1, D-10117 Berlin, Germany

[3] Berlin Inst Hlth, Charite Pl 1, D-10117 Berlin, Germany

[4] Charite Univ Med Berlin, Ctr Stroke Res Berlin, Charite Pl 1, D-10117 Berlin, Germany

[5] German Ctr Cardiovasc Res DZHK, Oudenarder Str 16, D-13347 Berlin, Germany

[6] German Ctr Neurodegenerat Dis DZNE, Partner Site Berlin,Charite Pl 1, D-10117 Berlin, Germany

[7] Charite Univ Med Berlin, Dept Neurosurg, Augustenburger Pl 1, D-13353 Berlin, Germany

[8] Heidelberg Univ Hosp, Dept Neurol, INF 400, D-69120 Heidelberg, Germany

[9] Univ Wurzburg, Dept Neurol, Josef Schneider Str 11, D-97080 Wurzburg, Germany

[10] Community Hosp Nuremberg, Dept Neurol, Breslauer Str 201, D-90471 Nurnberg, Germany

[11] UK RUB, Johannes Wesling Med Ctr Minden, Dept Neurol & Neurogeriatry, Hans Nolte Str 1, D-32429 Minden, Germany

[12] UK RUB, Johannes Wesling Med Ctr Minden, Dept Neurosurg, Hans Nolte Str 1, D-32429 Minden, Germany

[13] Univ Cologne, Dept Neurol, Kerpener Str 62, D-50937 Cologne, Germany

[14] Univ Munster, Dept Neurol, Albert Schweitzer Campus 1, D-48149 Munster, Germany

[15] Community Hosp Helios Klinikum Berlin Buch, Dept Neurol, Schwanebecker Chaussee 50, D-13125 Berlin, Germany

[16] Univ Dresden, Dept Neurol, Fetscherstr 74, D-01307 Dresden, Germany

[17] Univ Ulm, Dept Neurol, Oberer Eselsberg 45, D-89081 Ulm, Germany

[18] Community Hosp Asklepios Klin Hamburg Altona, Dept Neurol, Paul Ehrlich Str 1, D-22763 Hamburg, Germany

[19] Community Hosp Klinikum Dortmund, Dept Neurol, Beurhausstr 40, D-44137 Dortmund, Germany

[20] Community Hosp Klinikum Stuttgart, Dept Neurol, Kriegsbergstr 60, D-70174 Stuttgart, Germany

[21] Univ Leipzig, Dept Neurol, Liebigstr 20, D-04103 Leipzig, Germany

[22] Community Hosp Klinikum Stadt Ludwigshafen Rhein, Dept Neurol, Bremserstr 79, D-67063 Ludwigshafen, Germany

[23] Community Hosp Klinikum Koblenz, Dept Neurol, Kardinal Krementz Str 1-5, D-56073 Koblenz, Germany

[24] Community Hosp Bad Hersfeld, Dept Neurol, Seilerweg 29, D-36251 Bad Hersfeld, Germany

[25] Univ Jena, Dept Neurol, Erlanger Allee 101, D-07747 Jena, Germany

[26] Bezirkskrankenhaus Gunzburg, Dept Neurol & Neurol Rehabil, Ludwig Heilmeyer Str 2, D-89312 Gunzburg, Germany

[27] Univ Erlangen Nurnberg, Dept Neuroradiol, Schwabachanlage 6, D-91054 Erlangen, Germany

[28] Univ Erlangen Nurnberg, Dept Cardiol, Ulmenweg 18, D-91054 Erlangen, Germany

来源：

EUROPEAN HEART JOURNAL | 2018年 / 39卷 / 19期

关键词：

Intracerebral haemorrhage; Mechanical heart valve; Therapeutic anticoagulation; INTRACRANIAL HEMORRHAGE; EUROPEAN-SOCIETY; TASK-FORCE; REPLACEMENT; GUIDELINES; THROMBOSIS; WARFARIN; DISEASE; SCORE; RISK;

D O I：

10.1093/eurheartj/ehy056

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient- data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67-35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33-21.37; P < 0.01). The hazard for the composite-balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10-5.70; P = 0.03). Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing-between least risks for thromboembolic and haemorrhagic complications-provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk.

引用

页码：1709 / 1723

页数：15

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