Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke

Abstract

ImportanceUse 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.ObjectiveTo determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice.Design, Setting, and ParticipantsRetrospective, 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.ExposureVKA use within the 7 days prior to hospital arrival.Main Outcome and MeasuresThe 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.ResultsOf 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 RelevanceAmong 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.

Building evidence on safety of endovascular thrombectomy for patients under anticoagulation with vitamin K antagonists

“…However, recent VKA use with an INR >1.7 was associated with a significantly increased risk of sICH compared with the non‐VKA patients. 8 These findings provide practical information to select appropriate therapeutic strategies for AIS patients pretreated with VKA and offer access to EVT therapy for more anticoagulated patients.…”

“…In the issue of JAMA on June 20, 2023, Brian Mac Grory and colleagues 8 investigated the association between VKA use within the 7 days preceding hospital admission and the occurrence of sICH within 36 h among 32,715 patients undergoing EVT in 594 hospitals. Overlap weighting, a propensity score weighting method, was employed to achieve a precise balance in covariates between patients who were either taking or not taking a VKA.…”

Management and Prognosis of Acute Stroke in Atrial Fibrillation

“…This association was not found in DOAC patients. A newly published register-based study found recent use of VKA to significantly increase the risk of sICH (8.3%) after EVT if INR was higher than 1.7, compared with OAC-naïve patients [75]. DOAC treatment has also been associated with increased rates of successful reperfusion and better functional outcomes after EVT compared to VKA [76].…”

Vitamin K Antagonists and Intracranial Hemorrhage After Endovascular Thrombectomy

“…To the Editor I have some concerns about the recent article that investigated whether recent exposure to vitamin K antagonists (VKAs) in patients with acute ischemic stroke selected to undergo endovascular thrombectomy (EVT) increased the risk of symptomatic intracranial hemorrhage (sICH).…”