Abstract WP174: A Reassessment of Cost Effectiveness and Clinical Effectiveness of Anticoagulation Reversal in Direct Oral Anticoagulant - Related Intracerebral Hemorrhage

Abstract

Introduction: Anticoagulation use is associated with increased risk of hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH). We sought to assess rates of HE in patients with ICH on direct oral anticoagulants (DOAC) and annual cost associated with anticoagulation reversal and occurrence of HE. Methods: We performed an observational cohort study on consecutive patients with ICH on DOAC admitted to a Comprehensive Stroke Center over 3 years, using data from an institutional ICH registry. We prospectively collected baseline demographic and clinical variables, neuroimaging data on baseline and follow-up hematoma volumes (HV) and HE and outcomes on discharge via modified Rankin scale (mRS). Hemostatic efficacy on hematoma size was adjudicated based on the Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors-4 (ANNEXA-4) trial, with a ≤20% increase in HV compared to baseline considered “excellent” and a ≤ 35% increase in HV compared to baseline considered “good.” Weighted hematoma expansion cost was estimated based on common odds ratio of mRS increase with HE and distributions of mRS with HE. Results: We identified 103 patients who met inclusion criteria: mean age 75.8 (± 11.4) years, 55.3% female. 92 patients (89.3%) received anticoagulation reversal with prothrombin complex concentrate (PCC), of which 19 (20.7%) had HE. A more severe coagulopathy (antiXa > 0.5) was associated with increased risk of HE (p<0.05). 74 patients (80.4%) achieved good or excellent hemostasis. Use of PCC was associated with a 19.6% hematoma expansion rate using the definition above, which translates into a $6700 increase in annual cost per every ICH patient attributed to HE. Conclusion: Cost effective and clinically effective treatments for anticoagulation reversal are needed to reduce the risk and cost associated with HE in anticoagulation-related ICH.