Off-Label Use of Direct Oral Anticoagulants in Intracerebral Hemorrhage Patients With Prosthetic Valves.

Abstract

A 75-year-old man with a prosthetic mechanical valve presents with a cortical intracerebral hemorrhage and international normalized ratio of 2.7. Magnetic resonance imaging shows 3 to 4 microbleeds (mixed lobar and deep). Should the patient be resumed on warfarin or should off-label use of direct oral anticoagulants be considered? Off-label use of direct oral anticoagulants in intracerebral hemorrhage patients with prosthetic valves. ### Seemant Chaturvedi In this patient, the conventional treatment approach would be to place him back on a vitamin K antagonist (VKA) once the hemorrhage has stabilized and then recommend close monitoring of the international normalized ratio (INR) in the future. However, at times, an unconventional treatment strategy may be best for the patient. In this patient scenario, there are several facts to consider. First, the patient has already bled once in the brain with an INR within the therapeutic range. Second, he has evidence of microbleeds on magnetic resonance imaging, some of which are cortical. This raises concern for potential cerebral amyloid angiopathy. Third, it is known that patients with cerebral amyloid angiopathy have an elevated risk for oral anticoagulant (OAC)–related brain hemorrhage. Given this constellation of facts, it would be wise to discuss with the patient and family the full range of potential treatment options. On the basis of trials in patients with atrial fibrillation, it is established that direct oral anticoagulant (DOAC) medications have a substantially lower risk of intracerebral hemorrhage (ICH) compared with warfarin. The marked reduction in ICH makes DOACs particularly attractive for patients at increased ICH risk. This category includes elderly patients, patients in whom therapeutic anticoagulation is difficult to keep in the proper INR range and patients with prior ICH. Some clinicians may be hesitant to use DOACs in this patient because of the mechanical heart valve and lack of atrial fibrillation. However, patients …