Risk of hemorrhagic stroke in warfarin-treated patients following heart valve replacement: Findings from the MAGPIE...

Hemorrhagic stroke (HS) remains a serious and potentially disabling complication following heart valve replacement (HVR). We aimed to evaluate the incidence and predictors of HS among mechanical HVR patients in Bangladesh. The Multidimensional Approach of Genotype and Phenotype In Stroke Etiology (MAGPIE) is an ambispective study recruited 568 consecutive HVR patients who had long-term (≥6 months) warfarin therapy between January 2010 and December 2024. Among the 568 HVR patients, 4.4% experienced HS, with a mortality rate of 52%, and the median age was 40 years (interquartile range [IQR]: 32-45). The median duration of warfarin uses among mechanical heart valve patients with HS varied by procedure: 63 months (IQR: 48-86) for mitral valve replacement, 60 months (12-85) for aortic valve replacement, 96 months (52-101.50) for double valve replacement, and 42 months (24-60) for patients undergoing coronary artery bypass grafting (CABG) with valve replacement. Additionally, a receiver operating characteristic curve analysis identified 104 months as the discriminatory threshold for warfarin therapy duration in predicting post-HVR HS onset. An age- and sex-adjusted logistic regression model identified severe pulmonary hypertension (odds ratio [OR] 4.44; 95% confidence interval [CI] 1.15-17.04; p = 0.02) and warfarin therapy duration ≥104 months (OR 1.99; 95% CI 1.00-3.76; p = 0.04) as independent predictors of HS in patients with mechanical HVR. Severe pulmonary hypertension was associated with a 4.4-fold higher risk and warfarin therapy beyond 104 months with a twofold higher risk of HS among patients with mechanical HVR.