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Published on: August 16, 2021
The Dilemma of Resuming Antithrombotic Therapy After Intracranial Hemorrhage in Patients With Left Ventricular Assist
Christan D Santos1, Nikki L Matos2, Rabea Asleh3
1Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. Santos.Christan@mayo.edu.
Insights
Antithrombotic therapy resumption after intracranial hemorrhage (ICH) in left ventricular assist device (LVAD) patients is common. Recurrent hemorrhages occur in about a quarter of patients within a year, regardless of resumption timing.
Area of Science:
- Cardiology
- Neurology
- Medical Devices
Background:
- Antithrombotic therapy is crucial after left ventricular assist device (LVAD) implantation to prevent thromboembolic events.
- Intracranial hemorrhage (ICH) necessitates antithrombotic discontinuation, posing a risk for both bleeding and clotting.
- Optimal timing for antithrombotic resumption post-ICH in LVAD patients remains unclear.
Purpose of the Study:
- To investigate the timing of antithrombotic resumption after ICH in LVAD patients.
- To assess the association between resumption timing and the risk of recurrent hemorrhage and thrombotic events.
Main Methods:
- Multicenter, retrospective analysis of LVAD patients with ICH from 2010-2017.
- Included patients who resumed antithrombotics post-ICH.
- Analyzed covariates including age, INR, antithrombotic dosing, resumption timing, and outcomes within 1 year.
Main Results:
- 12.6% of LVAD patients (85/673) developed ICH.
- 41 patients resumed antithrombotics; median resumption was 5.5 days for aspirin, 6.5 days for warfarin.
- Within 1 year post-resumption, 26.8% experienced secondary hemorrhages, and 4.9% had thrombotic events.
- No significant difference in secondary hemorrhage risk was observed between early (<6 days) and late (≥6 days) resumption groups (P=0.75).
Conclusions:
- Recurrent hemorrhagic events are common (26.8%) within a year after antithrombotic resumption post-ICH in LVAD patients.
- The timing of antithrombotic resumption (early vs. late) did not significantly impact the risk of secondary hemorrhages.
Background/Objective:
Antithrombotic therapy is administered after left ventricular assist device (LVAD) implantation to prevent thromboembolic events. Intracranial hemorrhage (ICH) is a life-threatening adverse event requiring immediate discontinuation of antithrombotics. We investigated the timing of antithrombotic resumption after ICH in patients with LVADs and the association between timing and risk of recurrent hemorrhage and thrombotic events.
Methods:
We performed a multicenter, retrospective analysis of patients with ICH occurrence during LVAD antithrombotic regimen with subsequent resumption of antithrombotics from January 1, 2010, to December 31, 2017. Covariates included age, international normalized ratio, antithrombotic dosing, timing of resumption, modified Rankin score, and subsequent hemorrhagic and thrombotic events within 1 year post-ICH. Patients who did not resume anticoagulation were excluded.
Results:
Of 673 patients with LVADs, 85 (12.6%) developed ICH while being treated with antithrombotics. Forty-three were excluded due to death prior to resumption and one due to lack of resumption. The remaining 41 patients were on antithrombotics with a median (interquartile range [IQR]) international normalized ratio at ICH onset of 2.6 (1.8-3.6). Aspirin and warfarin were resumed at a median (IQR) of 5.5 (1.3-8.8) and 6.5 (4.0-15.5) days post-ICH, respectively. A continuous unfractionated heparin infusion was initiated in 16 (39.0%) patients at a median (IQR) of 2.5 (1.0-7.8) days post-ICH. During the 1-year follow-up after anticoagulation resumption, 11 (26.8%) patients suffered secondary hemorrhages and two (4.9%) suffered secondary thrombotic events. Using Kaplan-Meier method and log-rank test, we compared all patients who resumed anticoagulation by 6 days post-ICH to those who resumed after 6 days. There was no difference in freedom from secondary hemorrhagic event between the two groups (P = 0.75).
Conclusion:
Despite timing of resumption of antithrombotic therapy after ICH, recurrent hemorrhagic events can be expected in one-quarter of these patients over the subsequent year.
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