Abstract 3122: Delays in Warfarin Reversal following Intracerebral Hemorrhage: A Population-Based Study

Abstract

Introduction: Warfarin anticoagulation worsens outcomes following intracerebral hemorrhage (ICH), in part by increasing risk of hematoma expansion. Prompt reversal of warfarin anticoagulation is therefore imperative. We documented patterns of anticoagulant reversal following ICH in a large, population-based stroke study. Methods: As part of the Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study, we identified all patients who presented with an ICH to an emergency room in the five-county Greater Cincinnati/Northern Kentucky region from July 2008 through December 2009. Patients from outside the five-county region were excluded. We recorded all INRs, medications used to reverse coagulopathy, and mortality. For patients with warfarin-associated ICH and initial INR > 1.4, we determined the time from presentation to initiation of warfarin reversal and time to achievement of INR ≤ 1.4. We also compared times to warfarin reversal in centers with and without emergency medicine residency training programs (“academic” vs. “community” hospitals). Results: There were 403 cases of ICH identified at 13 local hospitals, including 67 cases of warfarin-associated ICH. After exclusion of patients with INR < 1.4 upon arrival, patients with stroke in the hospital, and patients who were made “comfort-care” within one hour of arrival, there were 53 cases of warfarin-associated ICH for analysis. Times of anticoagulation reversal are displayed in the table . Cryoprecipitate was given to one patients and platelets to two patients. No patients received promthrombin complex concentrates or recombinant activated factor VII. Use of FFP did not differ between academic hospitals and community hospitals, nor did time to FFP administration. Among 31 patients with documented reversal of anticoagulation to INR ≤ 1.4, time from FFP administration to INR normalization was less at academic centers, but this may have been a function of frequency of INR testing. Thirty-day mortality among the 53 analyzed cases was 49%. Conclusions: Reversal of coagulopathy was significantly delayed in our population, with a median time of > 3 hours from ED arrival to initiation of FFP. Only 31 of 53 analyzed cases had documented reversal of INR to ≤ 1.4, and this took a median of 11 hours. Improvements in time to warfarin reversal via streamlined systems or alternative medications such as prothrombin complex concentrates may improve patient outcomes.