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Kuramatsu JB, Sembill JA, Gerner ST, Sprügel MI, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Achenbach S, Schwab S, Huttner HB. Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves. Eur Heart J 2019. [PMID: 29529259 PMCID: PMC5950928 DOI: 10.1093/eurheartj/ehy056] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03). Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk. ![]()
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Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Jochen A Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany.,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße 16, Berlin 13347, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Sobesky
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Sigrid Wöpking
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Otto W Witte
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Albrecht Günther
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Straße 2, 89312 Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stephan Achenbach
- Department of Cardiology, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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Czerwińska-Jelonkiewicz K, Cisowski M, Bochenek A, Buszman P, Milewski K, Kunik P, Mularska M, Kocot K, Politowski P, Brączkowski J, Trznadel A, Aboodi MS, Buszman P. Low molecular weight heparin in surgical valve procedures: When and how much for an optimal prophylaxis? Cardiol J 2018; 27:548-557. [PMID: 30484265 DOI: 10.5603/cj.a2018.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Periprocedural antithrombotic prophylaxis in patients undergoing surgical valve procedures (SVP) is insufficiently investigated. Low molecular weight heparin (LMWH) has been considered as an alternative to unfractionated heparin (UFH). However, safety and efficacy of this prophylaxis strategy is unknown. This study aimed to investigate safety and efficacy of periprocedural LMWH prophylaxis and determine optimal dosage and timing for periprocedural cessation and initiation. METHODS The present study is a retrospective, single-center observational analysis of 388 patients who underwent SVP (valve replacement or valvuloplasty) between 2015 and 2016. In-hospital endpoints were bleeding, transfusions, reoperation due to bleeding, and thromboembolic events. RESULTS Giving the first dose of LMWH on the day of SVP was a risk factor for bleeding (OR 1.07; 95% CI 1.04-1.10; p < 0.001), transfusions (OR 1.04; 95% CI 1.01-1.07; p = 0.008) and reoperation due to bleeding (OR 1.20; 95% CI 1.12-1.28; p < 0.001), with > 40 mg/day as a predictor. A higher dosage of LMWH premedication was an independent risk factor for bleeding (OR 1.02; 95% CI 1.00-1.04; p = 0.03) and transfusion (OR 1.03; 95% CI 1.01-1.05; p = 0.01), with > 60 mg/day as a predictor for these events. LMWH dosed within 24 h prior to SVP increased the risk of transfusion (AUC 0.636; 95% CI 0.496-0.762; p = 0.04). CONCLUSIONS Bleeding is an important early concern after surgical valve procedures. Safety and efficacy of periprocedural prophylaxis with LMWH depends on dosage and the timing of its administration. The most optimal periprocedural prophylaxis in the SVP population appears to be LMWH in dosage of 40-60 mg/day, which is recommended for deep vein thrombosis prophylaxis, ceased at least one day before SVP.
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Affiliation(s)
| | - Marek Cisowski
- Ist Department of Cardiac Surgery, American Heart of Poland Inc, Armii Krajowej 101, 43-316 Bielsko-Biała, Poland
| | - Andrzej Bochenek
- Ist Department of Cardiac Surgery, American Heart of Poland Inc, Armii Krajowej 101, 43-316 Bielsko-Biała, Poland.,Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Piotr Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
| | - Piotr Kunik
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | | | - Krzysztof Kocot
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Piotr Politowski
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | | | - Agata Trznadel
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Michael S Aboodi
- Department of Medicine, Montefiore Medical Center, New York, United States
| | - Paweł Buszman
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland.,Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
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