Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

ObjectivesTo assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.MethodsData was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.ResultsThe final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59–82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC + AP).Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24 s; p < 0.001). Similarly patients on AC + AP also had higher INR (median 1.9) and aPTT (median 30 s) when compared to those not on AC/AP (p < 0.001).Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm3) when compared to those not on either AC/AP (median 27.2 cm3; p = 0.05). The same was not found for patients using AP (median volume 20.5 cm3; p = 0.813), or both AC + AP (median volume 27.7 cm3; p = 0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04–1.98; p = 0.035).There was no relationship between the use of AC/AP/AC + AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0–3.03; p = 0.05). No relationship was found between use of AP or AC + AP use and mortality.Of the 82 patients with INR > 1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4 U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24 h (median 1.2, IQR 1.1–1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death < 7 days) or functional outcome.ConclusionsAnticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.