Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
Neurocrit Care. 2020 Jun;32(3):822-827. doi: 10.1007/s12028-019-00836-y.
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.
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.
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).
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.
背景/目的：左心室辅助装置（LVAD）植入后进行抗血栓治疗，以预防血栓栓塞事件。颅内出血（ICH）是一种危及生命的不良事件，需要立即停止抗血栓治疗。我们研究了 LVAD 患者发生 ICH 后抗血栓治疗恢复的时机，以及时机与再出血和血栓事件风险之间的关系。
我们对 2010 年 1 月 1 日至 2017 年 12 月 31 日期间接受 LVAD 抗血栓治疗方案期间发生 ICH 并随后恢复抗血栓治疗的患者进行了一项多中心回顾性分析。协变量包括年龄、国际标准化比值、抗血栓治疗剂量、恢复时间、改良 Rankin 评分以及 ICH 后 1 年内的出血和血栓事件。排除未恢复抗凝治疗的患者。
在 673 例 LVAD 患者中，85 例（12.6%）在接受抗血栓治疗时发生 ICH。由于恢复前死亡 43 例，未恢复 1 例，故最终纳入 41 例患者。ICH 发病时，这 41 例患者的抗血栓治疗的国际标准化比值中位数（四分位距 [IQR]）为 2.6（1.8-3.6）。阿司匹林和华法林分别在 ICH 后中位数（IQR）5.5（1.3-8.8）和 6.5（4.0-15.5）天恢复。16 例（39.0%）患者在 ICH 后中位数（IQR）2.5（1.0-7.8）天开始连续输注未分级肝素。在抗凝恢复后的 1 年随访期间，11 例（26.8%）患者发生继发性出血，2 例（4.9%）发生继发性血栓事件。使用 Kaplan-Meier 法和对数秩检验，我们比较了 ICH 后 6 天内恢复抗凝的所有患者与 6 天后恢复抗凝的患者。两组患者继发性出血事件无差异（P=0.75）。
尽管 ICH 后抗血栓治疗恢复的时机不同，但在随后的 1 年内，仍有四分之一的患者可能会发生再发性出血事件。
