Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulant
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ORIGINAL ARTICLE
Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulants: a single hospital cohort study Senta Frol 1,2
&
Mišo Šabovič 3,4 & Janja Pretnar Oblak 1,2
Received: 14 June 2020 / Accepted: 25 September 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract Background Central nervous system (CNS) hemorrhage is a serious complication related to direct oral anticoagulant (DOAC) therapy. Current recommendations about re-initiation of anticoagulation treatment are limited to expert opinions. For this purpose, we analyzed the data of all consecutive DOAC patients with CNS hemorrhage, in whom DOACs were reinitiated. Methods Over a 6-year period (2012–2018), all consecutive patients with CNS hemorrhage (subdural, subarachnoid, intracerebral, spinal), while receiving DOACs, were included in this observational single-center cohort study. DOAC therapy was reinitiated only in patients with well-controlled arterial hypertension and diabetes, as well as exclusion of vascular malformations and cerebral amyloid angiopathy. The composite primary endpoint comprised of recurrent CNS hemorrhage, ischemic stroke, and mortality; secondary endpoints were separate aforementioned outcomes. Results Of the 54 patients included, 18 died within a month of CNS hemorrhage. The average observational time was 590 days. DOACs were reinitiated in 13/36 patients (36%); of these patients, three died: none due to ischemic stroke or recurrent CNS bleeding. In 23 patients, anticoagulation was not reinitiated; of these patients, 10 died: three from recurrent CNS hemorrhage, one due to ischemic stroke, and six from causes unrelated to stroke. Conclusions In carefully selected patients, re-initiation of DOAC therapy did not increase the rate of both endpoints. Recommendations for DOAC re-initiation, which include hypertension and diabetes control, as well as treated vascular malformations, and excluded cerebral amyloid angiopathy, appear to be valid in clinical practice. Keywords Direct oral anticoagulants . Atrial fibrillation . Cerebral amyloid angiopathy . Central nervous system hemorrhage . Stroke . Prognosis
Introduction * Senta Frol [email protected] Mišo Šabovič [email protected] Janja Pretnar Oblak [email protected] 1
Department of Vascular Neurology, University Medical Centre Ljubljana, Zaloška 2, 100 Ljubljana, Slovenia
2
Neurology Department, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
3
Department for Vascular Disorders, University Medical Centre Ljubljana, Ljubljana, Slovenia
4
Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
Though central nervous system (CNS) hemorrhage is an infrequent complication of anticoagulation therapy, it has a high mortality rate [1]. It has been demonstrated that direct oral anticoagulants (DOACs) are a safer and more effective anticoagulation therapy, compared with oral vitamin K antagonists (VKAs) [2–4]. According to multicenter, randomi
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