Should I start heparin (Heparin Sodium) infusion for a patient with a history of intracranial hemorrhage (ICH) and unstable angina?

From the Guidelines

You should not start heparin gtt for unstable angina in a patient with a history of intracranial hemorrhage (ICH) without careful consideration of the risks and benefits. The management of antithrombotic therapy in patients who have suffered an ICH is complex, and the decision to restart anticoagulation should be made on an individual basis, taking into account the type of hemorrhage, patient age, risk factors for recurrent hemorrhage, and indication for antithrombotic therapy 1. In patients with a history of ICH, the risk of recurrent hemorrhage must be weighed against the risk of an ischemic cerebrovascular event, and the decision to restart anticoagulation should be based on a careful assessment of these risks 1. Some studies suggest that intravenous heparin or low molecular weight heparin (LMWH) may be safer options for acute therapy than restarting oral warfarin in patients with compelling indications for early reinstitution of anticoagulation 1. However, the use of anticoagulation in patients with a history of ICH should be approached with caution, and the risks and benefits of therapy should be carefully considered on an individual basis 1. Key factors to consider when deciding whether to restart anticoagulation in a patient with a history of ICH include the type and location of the hemorrhage, the patient's age and comorbidities, and the indication for anticoagulation 1. In general, patients with a history of lobar ICH or those with evidence of cerebral amyloid angiopathy on MRI may be at higher risk of recurrent hemorrhage and may not be good candidates for anticoagulation therapy 1. Ultimately, the decision to start heparin gtt for unstable angina in a patient with a history of ICH should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, and after careful consideration of the potential risks and benefits of therapy.

From the FDA Drug Label

1. 2 Hemorrhage Avoid using heparin in the presence of major bleeding, except when the benefits of heparin therapy outweigh the potential risks. Use heparin sodium with caution in disease states in which there is increased risk of hemorrhage, including: • Hematologic - Conditions associated with increased bleeding tendencies, such as hemophilia, thrombocytopenia and some vascular purpuras • Other - Menstruation, liver disease with impaired hemostasis.

History of intracranial hemorrhage (ICH) is a significant risk factor for bleeding. Given the patient's history of ICH, the risk of bleeding with heparin therapy may outweigh the potential benefits.

• Heparin therapy is not recommended in patients with a history of major bleeding, such as ICH, unless the benefits of therapy clearly outweigh the risks.
• Alternative anticoagulant therapies may be considered, but the decision to start any anticoagulant therapy should be made with caution and careful consideration of the patient's individual risk factors 2.

From the Research

History of ICH and Unstable Angina

• The decision to start heparin gtt for unstable angina in patients with a history of intracranial hemorrhage (ICH) is complex and requires careful consideration of the risks and benefits 3, 4.
• Unstable angina is often caused by partial or complete coronary artery occlusion due to the disruption of an atherosclerotic plaque and to thrombus formation, and antithrombotic therapy is essential to prevent fatal and non-fatal myocardial infarction 5.
• However, the use of anticoagulants, including heparin, in patients with a history of ICH is associated with an increased risk of hemorrhagic complications 4, 6.

Risks and Benefits of Heparin Therapy

• The risk of immediate and delayed intracranial hemorrhages from initiating anticoagulation therapy in patients with a history of ICH must be weighed against the morbidity of delaying treatment 3.
• Low molecular weight heparins, such as enoxaparin, have been shown to be effective and safe in the management of unstable angina, with a comparable rate of major hemorrhage to unfractionated heparin 5, 7.
• However, the use of heparin in patients with a history of ICH requires careful monitoring and consideration of the risks and benefits, and the decision to start heparin gtt should be made on a case-by-case basis 6.

Management of Anticoagulation-Related ICH

• In the event of anticoagulation-related ICH, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes 6.
• The Neurocritical Care Society and Society of Critical Care Medicine have developed guidelines for the reversal of antithrombotics in intracranial hemorrhage, which provide evidence-based recommendations for the management of patients with antithrombotic-associated ICH 6.