Making anticoagulation safer.

Abstract

The Smith et al. case-control study compared patients with warfarin-related intracerebral hemorrhage (ICH) and previous stroke vs age-matched poststroke patients on warfarin without ICH. The presence and severity of leukoaraiosis correlated strongly with ICH and was seen in 92% of ICH vs 48% of controls: odds ratio, 12.9. see following Commentary by Robert G. Hart, MD Oral anticoagulation with vitamin K antagonists has been prescribed for stroke prevention for over 50 years, but only during the past decade have the benefits and risks been defined by adequate randomized clinical trials. Bleeding is the major toxicity, and most fatal bleeds are ICH. Some 5,000 to 10,000 warfarin-associated ICHs occur yearly in the United States. Advanced patient age, anticoagulation intensity, and “cerebrovascular disease” are accepted risk factors for warfarin-associated ICH. Intensity of anticoagulation is the strongest, most consistent predictor, and targeting the lowest efficacious international normalized ratio is important. Recently, two novel predictors have been proposed in Neurology : APOE genotype (as a marker of cerebral amyloid angiopathy)1 and “leukoaraiosis” evident on cranial CT scanning in noncardioembolic brain ischemia. (Smith et al. in this issue and Gorter2). Although these novel predictors offer pathogenetic clues, neither has been sufficiently validated …