INTRACEREBRAL HEMORRHAGE
Risk and prevention of bleeding in anticoagulant therapy
Created 15/04/2021, last revision 20/11/2023
- anticoagulant therapy is associated with an increased risk of clinically significant bleeding
- however, antiplatelet therapy is not a safe and effective substitute
- specific scales can be used to assess the individual risk of bleeding (see below)
- always weigh the benefits of therapy against its risks
- risk of bleeding (mainly intracranial): DOAC < warfarin
Etiopathogenesis of anticoagulation-related bleeding
- anticoagulants are associated with an increased risk of bleeding, and this bleeding is more likely to be clinically significant
- several factors can trigger intracerebral bleeding → see here
- arterial rupture in hypertensive patient (hypertensive arteriolopathy)
- according to the CROMIS-2 trial, cerebral microbleeds (CMBs) on GRE double the risk of bleeding
- according to the CROMIS-2 trial, cerebral microbleeds (CMBs) on GRE double the risk of bleeding
- rupture of vascular malformation
- cerebral amyloid angiopathy (CAA)
- trauma
- tumor invasion
- sepsis
- hemorrhagic stroke
- arterial rupture in hypertensive patient (hypertensive arteriolopathy)
- screening for occult bleeding, malformation, or CMBs is not a routine part of the assessment before starting anticoagulant therapy.
- systemic bleeding most usually occurs in the gastrointestinal or urogenital tract
Risk factors
- modifiable risk factors
- blood pressure
- drug interactions
- correct anticoagulant dose (e.g., based on weight and/or renal function)
- mon-modifiable risk factors (cannot be changed)
- age
- race/ethnicity
- comorbidities (renal insufficiency, hepatopathy, etc.)
- previous ICH (Schreuder, 2021)
Anticoagulant drug and dose
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Age, race
- older age is associated with a higher risk of bleeding, but it is not a reason to withhold the therapy
- dabigatran dose should be reduced at ages ≥ 75-80 (see specifics of each drug)
- race – higher risk in Asians, Hispanics, and blacks
Recent ischemic stroke
- in the first days and weeks after a stroke, there is an increased risk of bleeding within the ischemic area (hemorrhagic transformation of ischemia)
- timing of anticoagulation is guided by the patient’s clinical status (NIHSS), compensation of risk factors (BP, platelets count, coagulation), and CT scan findings (localization and extent of ischemia)
History of bleeding
- previous bleeding increases risk of recurrence
- individualized assessment is necessary, but reinstitution of anticoagulant therapy is usually possible and associated with reduced all-cause mortality [Witt, 2018]
- risk of GI bleeding can be assessed by endoscopic findings
- risk of IC bleeding depends on the etiology and modifiable risk factors
- postoperative bleeding is a transient risk factor
Other comorbidities
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Thrombocytopenia and thrombocytopathy
Other specific risk factors
Bleeding risk scales
Reduction of bleeding risks
- correct indication of anticoagulant therapy (regularly check whether the indication is still valid)
- choose the drug with the best risk-benefit profile (prefer DOACs over VKA if possible)
- choose the right dose
- unjustified dose reduction due to fear of bleeding is likely to increase the risk of ischemic stroke → see Reduced-dose DOACs
- unjustified dose reduction due to fear of bleeding is likely to increase the risk of ischemic stroke → see Reduced-dose DOACs
- monitor anticoagulated patients regularly (even those on DOACs!)
- consider LAA occlusion
In a patient on anticoagulant therapy, check at each visit:
Adherence – check compliance + repeat education
-
- switch from warfarin to DOAC (if possible) when INR fluctuates, but good adherence is essential (missing a single dose of DOAC has a greater impact than missing a single dose of warfarin)
- repeatedly educate the patient on the correct use of the medication
- advise the patient to carry a medication chart and anticoagulant therapy card in their pocket
Bleeding risk assessment
-
- search for bleeding complications
- review bleeding risk scales – HAS-BLED score
- use PPIs if necessary
- assess the need for dose reduction or drug switching
Creatinine clearance (according to Cockcroft-Gault) – monitor renal function, adjust DOAC dose if needed
-
- every 12 months in healthy patients < 75 years of age
- every 6 months in patients ≥ 75 years of age or frail individuals
- CrCl/10 is an interval in months in patients with CrCl < 60 mL/min
Drug interaction
-
- check for drug interactions – may increase bleeding risk or reduce the anticoagulant effect (e.g., antirheumatic drugs, verapamil in patients on dabigatran, etc.) → see the chapter on DOACs
- check for drug interactions – may increase bleeding risk or reduce the anticoagulant effect (e.g., antirheumatic drugs, verapamil in patients on dabigatran, etc.) → see the chapter on DOACs
Examination and other
-
- monitor blood pressure and weight
- any signs of thromboembolism or bleeding?
- any adverse reactions?
- laboratory tests, besides CrCl, may include:
- blood count, renal and liver tests (at least annually, more frequently in individual cases)
- specific tests to monitor the anticoagulant effect in selected patients