Should oral anticoagulants be restarted after warfarin-associated cerebral haemorrhage in patients with atrial fibrillation?

Maurizio Paciaroni; Giancarlo Agnelli

doi:10.1160/TH13-08-0667

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2014; 111(01): 14-18
DOI: 10.1160/TH13-08-0667

Clinical Focus

Schattauer GmbH

Should oral anticoagulants be restarted after warfarin-associated cerebral haemorrhage in patients with atrial fibrillation?

Maurizio Paciaroni

¹Stroke Unit and Division of Internal and Cardiovascular Medicine, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy

,

Giancarlo Agnelli

¹Stroke Unit and Division of Internal and Cardiovascular Medicine, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy

› Author Affiliations

Abstract

Summary

Intracranial haemorrhage (ICH), which affects up to 1% of patients on oral anticoagulation per year, is the most feared and devastating complication of this treatment. After such an event, it is unclear whether anticoagulant therapy should be resumed. Such a decision hinges upon the assessment of the competing risks of haematoma growth or recurrent ICH and thromboembolic events. ICH location and the risk for ischaemic cerebrovascular event seem to be the key factors that lead to risk/benefit balance of restarting anticoagulation after ICH. Patients with lobar haemorrhage or cerebral amyloid angiopathy remain at higher risk for anticoagulant-related ICH recurrence than thromboembolic events and, therefore would be best managed without anticoagulants. Patients with deep hemispheric ICH and a baseline risk of ischemic stroke >6.5% per year, that corresponds to CHADS₂ ≥ 4 or CHA₂DS₂-VASc ≥ 5, may receive net benefit from restarting anticoagulation. To date, a reasonable recommendation regarding time to resumption of anticoagulation therapy would be after 10 weeks. Available data regarding the role of magnetic resonance imaging in assessing the risks of both ICH and warfarin-related ICH do not support the use of this test for excluding anticoagulation in patients with atrial fibrillation.

Keywords

Cerebral haemorrhage - warfarin - anticoagulants - atrial fibrillation

Full Text

References

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