Background:
Direct-oral-anticoagulant (DOAC) and warfarin treatment are associated with increased risk of intracerebral hemorrhage (ICH). Specific warfarin and dabigatran reversal agents exist. Data on protocol-guided non-specific 3-factor Prothrombin Complex Concentrate (PCC) Factor Xa inhibitor (FXAI) reversal is lacking.
Aims:
Our retrospective cohort study aimed to assess Factor Xa-related (FXAI) ICH trends, and compare rates and timeliness of antihypertensive and reversal treatments.
Methods:
We included patients with anticoagulation-related non-traumatic ICH of <24 hours duration from South Australian Stroke units (Dec 2016-Dec 2023). Outcomes analyzed included 30-day mortality and discharge modified-Rankin-Scale (mRS). Secondary outcomes included time to administration of reversal agent, intravenous anti-hypertensives, and time to systolic blood pressure (BP) lowering <140 mmHg.
Results:
Of 2229 total ICH, 389 were anticoagulation-related (108 warfarin, 16 dabigatran, and 264 FXAI). The proportion of FXAI-related ICH increased from 4% in 2017 to 26% in 2023. Of 238 included patients (mean age 81(SD 10)) 165 (69%) were in the FXAI group and 73 (31%) in the warfarin/dabigatran group. The dabigatran/warfarin group was significantly more likely to receive reversal (56% dabigatran/warfarin vs FXAI 39% (OR, 2.1; 95% CI, 1.6-2.7). Time to reversal (when performed) did not differ between groups (138.4 minutes (SD 85.6) dabigatran/warfarin vs FXAI 153.2 (SD 164.2); p=0.6), nor did time to first dose of intravenous anti-hypertensives, time to BP <140mmHg, and 30-day mortality.
Conclusion:
FXAI-related ICH is proportionally increasing. In anticoagulated ICH patients, time to anticoagulation reversal and initiation of first IV anti-hypertensive was suboptimal irrespective of the pre-ICH anticoagulant.