Original Investigation
June 20, 2023
Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke
Brian Mac Grory, DaJuanicia N. Holmes, Roland A. Matsouaka, et al
JAMA. 2023;329(23):2038-2049. doi:10.1001/jama.2023.8073
Question In patients with acute ischemic stroke due to large vessel occlusion selected to receive endovascular thrombectomy (EVT), does recent exposure to vitamin K antagonists (VKAs) increase the risk of symptomatic intracranial hemorrhage?
Findings In this retrospective, registry-based study that included 32 715 patients with acute ischemic stroke treated with EVT, symptomatic intracranial hemorrhage occurred in 6.8% of patients with recent use of a VKA and in 6.4% of patients with no preceding use of an oral anticoagulant, a difference that was not statistically significant after multivariable adjustment. However, the subgroup of patients with recent use of a VKA and a presenting international normalized ratio greater than 1.7 had a significantly increased risk of symptomatic intracranial hemorrhage (8.3%) compared with those taking no oral anticoagulant.
Meaning Among patients with acute ischemic stroke selected to undergo EVT, recent use of a VKA was not significantly associated with an increased risk of symptomatic intracranial hemorrhage overall, although the risk was significantly increased among the subgroup of patients with recent VKA use and an elevated international normalized ratio at the time of presentation.
Abstract
Importance Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications.
Objective To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice.
Design, Setting, and Participants Retrospective, observational cohort study based on the American Heart Association’s Get With the Guidelines–Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included.
Exposure VKA use within the 7 days prior to hospital arrival.
Main Outcome and Measures The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice.
Results Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, −0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, −0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups.
Conclusions and Relevance Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.
