Kuramatsu, Joji B., Gerner, Stefan T. ORCID: 0000-0001-6020-8290, Schellinger, Peter D., Glahn, Joerg, Endres, Matthias, Sobesky, Jan, Flechsenhar, Julia, Neugebauer, Hermann ORCID: 0000-0003-3759-356X, Juettler, Eric, Grau, Armin, Palm, Frederick, Roether, Joachim, Michels, Peter, Hamann, Gerhard F., Huewel, Joachim, Hagemann, Georg, Barber, Beatrice, Terborg, Christoph, Trostdorf, Frank, Baezner, Hansjoerg, Roth, Aletta, Woehrle, Johannes, Keller, Moritz, Schwarz, Michael, Reimann, Gernot, Volkmann, Jens ORCID: 0000-0002-9570-593X, Muellges, Wolfgang, Kraft, Peter, Classen, Joseph ORCID: 0000-0001-7182-6967, Hobohm, Carsten, Horn, Markus, Milewski, Angelika, Reichmann, Heinz, Schneider, Hauke ORCID: 0000-0002-9641-0922, Schimmel, Eik, Fink, Gereon R. ORCID: 0000-0002-8230-1856, Dohmen, Christian, Stetefeld, Henning, Witte, Otto ORCID: 0000-0003-2101-4105, Guenther, Albrecht, Neumann-Haefelin, Tobias, Racs, Andras E., Nueckel, Martin, Erbguth, Frank, Kloska, Stephan P., Doerfler, Arnd, Koehrmann, Martin, Schwab, Stefan and Huttner, Hagen B. (2015). Anticoagulant Reversal, Blood Pressure Levels, and Anticoagulant Resumption in Patients With Anticoagulation-Related Intracerebral Hemorrhage. JAMA-J. Am. Med. Assoc., 313 (8). S. 824 - 837. CHICAGO: AMER MEDICAL ASSOC. ISSN 1538-3598

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Abstract

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.

Item Type: Journal Article
Creators:
CreatorsEmailORCIDORCID Put Code
Kuramatsu, Joji B.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Gerner, Stefan T.UNSPECIFIEDorcid.org/0000-0001-6020-8290UNSPECIFIED
Schellinger, Peter D.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Glahn, JoergUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Endres, MatthiasUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Sobesky, JanUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Flechsenhar, JuliaUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Neugebauer, HermannUNSPECIFIEDorcid.org/0000-0003-3759-356XUNSPECIFIED
Juettler, EricUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Grau, ArminUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Palm, FrederickUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Roether, JoachimUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Michels, PeterUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Hamann, Gerhard F.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Huewel, JoachimUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Hagemann, GeorgUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Barber, BeatriceUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Terborg, ChristophUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Trostdorf, FrankUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Baezner, HansjoergUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Roth, AlettaUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Woehrle, JohannesUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Keller, MoritzUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Schwarz, MichaelUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Reimann, GernotUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Volkmann, JensUNSPECIFIEDorcid.org/0000-0002-9570-593XUNSPECIFIED
Muellges, WolfgangUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Kraft, PeterUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Classen, JosephUNSPECIFIEDorcid.org/0000-0001-7182-6967UNSPECIFIED
Hobohm, CarstenUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Horn, MarkusUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Milewski, AngelikaUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Reichmann, HeinzUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Schneider, HaukeUNSPECIFIEDorcid.org/0000-0002-9641-0922UNSPECIFIED
Schimmel, EikUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Fink, Gereon R.UNSPECIFIEDorcid.org/0000-0002-8230-1856UNSPECIFIED
Dohmen, ChristianUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Stetefeld, HenningUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Witte, OttoUNSPECIFIEDorcid.org/0000-0003-2101-4105UNSPECIFIED
Guenther, AlbrechtUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Neumann-Haefelin, TobiasUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Racs, Andras E.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Nueckel, MartinUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Erbguth, FrankUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Kloska, Stephan P.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Doerfler, ArndUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Koehrmann, MartinUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Schwab, StefanUNSPECIFIEDUNSPECIFIEDUNSPECIFIED
Huttner, Hagen B.UNSPECIFIEDUNSPECIFIEDUNSPECIFIED
URN: urn:nbn:de:hbz:38-407254
DOI: 10.1001/jama.2015.0846
Journal or Publication Title: JAMA-J. Am. Med. Assoc.
Volume: 313
Number: 8
Page Range: S. 824 - 837
Date: 2015
Publisher: AMER MEDICAL ASSOC
Place of Publication: CHICAGO
ISSN: 1538-3598
Language: English
Faculty: Unspecified
Divisions: Unspecified
Subjects: no entry
Uncontrolled Keywords:
KeywordsLanguage
ATRIAL-FIBRILLATION; HEMATOMA EXPANSION; VITAMIN-K; WARFARIN; STROKE; RISK; MANAGEMENT; VALIDATION; GUIDELINES; INTENSITYMultiple languages
Medicine, General & InternalMultiple languages
URI: http://kups.ub.uni-koeln.de/id/eprint/40725

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