Document Detail

Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis.
MedLine Citation:
PMID:  12805495     Owner:  NLM     Status:  MEDLINE    
BACKGROUND AND PURPOSE: Warfarin increases both the likelihood and the mortality of intracerebral hemorrhage (ICH), particularly in patients with a history of prior ICH. In light of this consideration, should a patient with both a history of ICH and a clear indication for anticoagulation such as nonvalvular atrial fibrillation be anticoagulated? In the absence of data from a clinical trial, we used a decision-analysis model to compare the expected values of 2 treatment strategies-warfarin and no anticoagulation-for such patients. METHODS: We used a Markov state transition decision model stratified by location of hemorrhage (lobar or deep hemispheric). Effectiveness was measured in quality-adjusted life years (QALYs). Data sources included English language literature identified through MEDLINE searches and bibliographies from selected articles, along with empirical data from our own institution. The base case focused on a 69-year-old man with a history of ICH and newly diagnosed nonvalvular atrial fibrillation. RESULTS: For patients with prior lobar ICH, withholding anticoagulation therapy was strongly preferred, improving quality-adjusted life expectancy by 1.9 QALYs. For patients with prior deep hemispheric ICH, withholding anticoagulation resulted in a smaller gain of 0.3 QALYs. In sensitivity analyses for patients with deep ICH, anticoagulation could be preferred if the risk of thromboembolic stroke is particularly high. CONCLUSIONS: Survivors of lobar ICH with atrial fibrillation should not be offered long-term anticoagulation. Similarly, most patients with deep hemispheric ICH and atrial fibrillation should not receive anticoagulant therapy. However, patients with deep hemispheric ICH at particularly high risk for thromboembolic stroke or low risk of ICH recurrence might benefit from long-term anticoagulation.
Mark H Eckman; Jonathan Rosand; Katherine A Knudsen; Daniel E Singer; Steven M Greenberg
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Publication Detail:
Type:  Comparative Study; Journal Article; Research Support, Non-U.S. Gov't     Date:  2003-06-12
Journal Detail:
Title:  Stroke; a journal of cerebral circulation     Volume:  34     ISSN:  1524-4628     ISO Abbreviation:  Stroke     Publication Date:  2003 Jul 
Date Detail:
Created Date:  2003-07-04     Completed Date:  2003-08-01     Revised Date:  2006-11-15    
Medline Journal Info:
Nlm Unique ID:  0235266     Medline TA:  Stroke     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1710-6     Citation Subset:  IM    
Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA.
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MeSH Terms
Anticoagulants / adverse effects*,  therapeutic use
Aspirin / adverse effects,  therapeutic use
Atrial Fibrillation / complications,  drug therapy
Cerebral Hemorrhage / chemically induced*,  prevention & control*
Cohort Studies
Decision Support Techniques*
Fibrinolytic Agents / adverse effects,  therapeutic use
Intracranial Thrombosis / etiology,  prevention & control
Markov Chains
Quality-Adjusted Life Years
Risk Assessment
Sensitivity and Specificity
Warfarin / adverse effects*,  therapeutic use
Reg. No./Substance:
0/Anticoagulants; 0/Fibrinolytic Agents; 50-78-2/Aspirin; 81-81-2/Warfarin
Comment In:
Stroke. 2003 Nov;34(11):e217-8; author reply e217-8   [PMID:  14563956 ]
Stroke. 2004 Jan;35(1):e5-6; author reply e5-6   [PMID:  14671234 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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