How soon after an intracerebral hemorrhage (ICH) can anticoagulant therapy be restarted?

From the Guidelines

Anticoagulant therapy can be restarted 4 weeks after an intracerebral hemorrhage (ICH) in patients without mechanical heart valves, as this may decrease the risk of ICH recurrence 1. The decision to restart anticoagulation after ICH should be individualized based on patient-specific factors, including the risk of recurrent hemorrhage and the risk of thromboembolic events.

• Factors that may influence the decision to restart anticoagulation include:
  • Thromboembolic risk: patients with high thromboembolic risk, such as those with mechanical heart valves, atrial fibrillation with high CHADS2-VASc scores, or recent venous thromboembolism, may require earlier restart of anticoagulation.
  • ICH location and size: lobar location and larger ICH size may increase the risk of recurrence and delay resumption of anticoagulation.
  • Patient age and comorbidities: older age, presence of cerebral amyloid angiopathy, and ongoing alcohol use may also delay resumption of anticoagulation.
• Before restarting anticoagulation, it is essential to:
  • Control blood pressure (typically <130/80 mmHg) 1.
  • Address modifiable risk factors.
  • Consider neuroimaging to confirm hemorrhage stabilization. The optimal timing for restarting anticoagulation after ICH is uncertain, but avoidance of oral anticoagulation for at least 4 weeks may decrease the risk of ICH recurrence 1. When restarting anticoagulation, consider beginning with a lower intensity regimen or using agents with potentially lower intracranial bleeding risk, such as apixaban or dabigatran 1. Ultimately, the decision to restart anticoagulation after ICH should balance the risk of recurrent hemorrhage against the risk of thromboembolic events, and be guided by the most recent and highest quality evidence available 1.

From the Research

Timing of Anticoagulant Restart after Intracerebral Hemorrhage

The decision on when to restart anticoagulant therapy after an intracerebral hemorrhage (ICH) is complex and depends on various factors, including the patient's risk of thromboembolic events and the risk of recurrent hemorrhage.

• Studies suggest that restarting anticoagulant therapy too early can increase the risk of recurrent hemorrhage, while delaying it may increase the risk of thromboembolic events 2, 3, 4.
• A study published in the European Heart Journal found that restarting anticoagulant therapy within 13 days after ICH was associated with increased hemorrhagic complications, and the optimal time to restart was found to be around Day 6 for patients at high thromboembolic risk 2.
• Another study published in the Annals of Translational Medicine suggested that halting anticoagulant therapy for 3 to 7 days may be safe, and recommended the use of low molecular heparin as a bridge treatment, combined with warfarin anticoagulant therapy within 1 week after hemorrhage 3.
• Expert opinions and systematic reviews also suggest that anticoagulant therapy can be restarted within a few days to a few weeks after ICH, but the exact timing depends on individual patient factors and the risk-benefit assessment 5, 4, 6.

Factors Influencing the Decision to Restart Anticoagulant Therapy

Several factors influence the decision to restart anticoagulant therapy after ICH, including:

• The patient's underlying condition, such as the presence of a mechanical heart valve or atrial fibrillation 2, 3, 6.
• The risk of recurrent hemorrhage, which is higher in patients with a history of previous ICH or those with certain underlying conditions 2, 4.
• The risk of thromboembolic events, which is higher in patients with atrial fibrillation or mechanical heart valves 2, 3, 6.
• The patient's functional status and ability to tolerate anticoagulant therapy 6.

Clinical Practice Variations

There is significant variation in clinical practice regarding the management of anticoagulant therapy after ICH, with different strategies used to normalize INR and restart anticoagulation 6.

• A nationwide survey of neuro-specialists found that the majority of respondents stopped warfarin medication and normalized INR on admission, but the timing of restarting anticoagulation varied widely, ranging from within 4 days to 29 days or later 6.