Warfarin's effect on stroke outcomes
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Warfarin’s effect on stroke outcomes Warfarin is associated with increased mortality and disability after intracerebral haemorrhage (ICH), according to an abstract presented at the 2011 International Stroke Conference.1 The investigators retrospectively analysed 1661 cases of ICH* over a 10-year period. They evaluated the change from baseline in ICH and intraventricular haemorrhage (IVH) volume. Outcomes were also assessed using the modified Rankin Scale over 90 days. Oral anticoagulants are associated with a higher risk of ICH and IVH expansion (odds ratio [OR] 4.45; p < 0.001 and OR 1.5; p < 0.05, respectively). It was found that the ICH and IVH volumes were significantly larger in warfarin recipients at baseline, with a dose response relationship between warfarin INR and the haemorrhage volume. Patients with hypertension taking oral anticoagulants and an INR of > 2 were at the highest risk of IVH expansion (OR 3; p < 0.05).
Impact of other stroke therapies In another abstract from the same conference, researchers from Canada investigated the effects of their newly approved prothrombin complex concentrate (PCC), for the reversal of anticoagulation, in patients with anticoagulant-associated intracranial haemorrhage (AAICH).2 Using the prospective CanPro registry** and a chart review they identified thrombotic events within 30 days of PCC therapy. For the 105 patients treated with a median dose of 1000U PCC, 80.3% of patients had complete INR correction (< 1.5) within 1 hour of PCC therapy. This increased to 87% over 10 hours. Despite this positive correction in INR levels; in hospital mortality was high, particularly in patients with ICH and subdural haemorrhage (45% and 44%, respectively). The researchers say that while INR correction is necessary, it "may not be sufficient to alter the poor prognosis in AAICH". A similar study, investigated the effects of treating patients with acute ischaemic stroke, who have been receiving warfarin, with alteplase within 0-3 hours of stroke onset.3 The researchers found these patients had a higher overall risk of symptomatic ICH when treated with IV alteplase compared with the overall known risk (6%). Using a retrospective chart review the researchers assessed the rates of ICH. They found that while lower INR levels were associated with less haemorrhage, there was no correlation between the INR level and the risk of symptomatic ICH (OR 0.2). * 796 cases lobar cases and 865 non-lobar cases ** Canadian Prothrombin Complex Concentrate Registy of patients treated with PCC for AAICH 1. Biffi A, et al. Warfarin, small vessel disease and outcome after intracerebral hemorrhage. 36th International Stroke Conference : abstr. 51, 9 Feb 2011. Available from: URL: http://strokeconference.americanheart.org. 2. Dowlatshahi D, et al. Poor prognosis in warfarin-associated intracranial hemorrhage despite prothrombin complex concentrate therapy: the CanPro Registry. 36th International Stroke Conference : abstr. W MP33, 9 Feb 2011. Available from: URL: http://strokeconference.americanheart.or
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