Prosthetic Valve;Anticoagulation After ICH

Dr.Tahsin.N

Complications

A meta-analysis in 1994 - not anticoagulated

Prosthetic valve thrombosis - 1.8% per patient-year (95% CI 0.9–3.0%).

Mechanical valve embolism resulting in death, stroke or peripheral

ischaemia requiring surgery 4% per patient-year (95% CI 2.9–5.2%).

This is reduced to 2.2% by antiplatelet drugs and 1.0% per patient-year

with warfarin.

Risk of ICH increased by 7–10 fold, to an absolute risk of 0.3–1% per year.

The mortality associated with oral anticoagulant related ICH is about 60%

The risk of ICH recurrence - 2% to 4% per patient-year.

Lobar hemorrhage or cerebral amyloid angiopathy - higher risk of anticoagulant related ICH recurrence than thromboembolic events – No anticoagulants.

Deep hemispheric ICH/ hypertension that can be well controlled and high risk of thromboembolism – Anticoagulation

Risk factors - Recurrent bleed

• Amyloid angiopathy – Lobar haemorrrhage (4% Vs 2%)

• The presence and number of microbleeds on T2-wted gradient-echo MRI

• Apolipoprotein E genotype58

• High Blood pressure

• High INR

Timing

The European Stroke Initiative :patients with a strong indication for anticoagulation

should be restarted on warfarin after 10 to 14 days, depending on the risk of

thromboembolism and ICH recurrence.

The American Heart Association : patients with a very high risk of thromboembolism

for whom restarting warfarin is considered, warfarin may be restarted 7 to 10 days

after ICH onset.

The American College of Chest Physicians : start prophylactic dose heparin the day

after an ICH - no clear guidance on restarting warfarin.

THANK YOU