Poster The Joint Annual Meeting of the Stroke Society of Australasia (SSA) and Smartstrokes 2023

Anticoagulation associated intracerebral hemorrhage treatment and outcomes analysed by the potential availability of specific vs non-specific reversal agents: a retrospective cohort study. (#206)

Shaddy El-Masri 1 , Rudy Goh 1 , Stephen Bacchi 1 , Lachlan Tamlin 1 , Sarah Howson 1 , Siqi Chen 1 , Brandon Stretton 1 , Daniel Zweck 1 , Christopher Ovenden 1 , Matthew Willcourt 1 , Andrew Moey 1 , Jim Jannes 1 , Timothy Kleinig 1
  1. The Royal Adelaide Hospital, Adelaide, SOUTH AUSTRALIA, Australia

Background:

Direct oral anticoagulant (DOAC) and warfarin treatment are associated with increased risk of intracerebral hemorrhage (ICH). Specific reversal agents only currently exist in Australia for warfarin and dabigatran; ‘reversal’ of apixaban and rivaroxaban using 3-factor Prothrombin Complex Concentrate (PCC) is included in many protocols, however data on the speed and effectiveness of these treatments is lacking.

Aims:

Our retrospective cohort study aimed to compare rates of non-dabigatran DOAC-related reversal with dabigatran/warfarin-related reversal following ICH. We also assessed the timeliness of administration of reversal agents and intravenous (IV) anti-hypertensives and their impact on mortality and functional outcomes.

Methods:

We analyzed data from electronic medical records from inception until December 2022 in South Australian Tertiary Hospitals. Patients with non-traumatic ICH and a last known well time of <24 hours were included, while those with isolated intraventricular hemorrhage or secondary causes of ICH were excluded. Outcomes analyzed included 30-day mortality and discharge modified Rankin Scale (mRS). Secondary outcomes included time to administration of reversal agent, intravenous anti-hypertensives, and time to systolic blood pressure (BP) lowering below 140 mmHg.

Results:

We included 102 patients (mean age 82 (SD 9)) of whom 74 (73%) were in the non-dabigatran DOAC group and 28 (27%) in the warfarin/dabigatran group. Reversal agent rates did not differ (46% dabigatran/warfarin vs non-dabigatran-DOAC 39% (OR, 1.4; 95% CI, 0.93-2.08). Time to reversal also did not differ (91.7 minutes (SD 137) dabigatran/warfarin vs non-dabigatran-DOAC 141 (SD 229); p=0.3).  Time to first dose of IV anti-hypertensives also did not differ, nor average time from arrival to achieved BP <140. There was no difference in 30-day mortality between the two groups.

Conclusion:

In anticoagulated ICH patients, time to anticoagulation reversal and initiation of first IV anti-hypertensive was greater than 120 minutes irrespective of the pre-ICH anticoagulant. Greater effort should be made to improve time-to-treatment in both groups.