Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage

Author:

Sheth Kevin N.1,Solomon Nicole2,Alhanti Brooke2,Messe Steven R.3,Xian Ying4,Bhatt Deepak L.5,Hemphill J. Claude6,Frontera Jennifer A.7,Chang Raymond C.8,Danelich Ilya M.8,Huang Joanna8,Schwamm Lee9,Smith Eric E.10,Goldstein Joshua N.11,Mac Grory Brian12,Fonarow Gregg C.13,Saver Jeffrey L.14

Affiliation:

1. Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut

2. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina

3. Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia

4. Department of Neurology, University of Texas at Southwestern, Dallas

5. Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York

6. Department of Neurology, University of California, San Francisco

7. Department of Neuology, New York University, New York

8. AstraZeneca, Wilmington, Delaware

9. Department of Biomedical Informatics and Data Sciences, Yale School of Medicine, New Haven, Connecticut

10. Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada

11. Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston

12. Department of Neurology, Duke University School of Medicine, Durham, North Carolina

13. Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California

14. Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, California

Abstract

ImportanceIntracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice.ObjectiveTo evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions.Design, Setting, and ParticipantsThis cohort study used data from the American Heart Association Get With The Guidelines–Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023.ExposuresAnticoagulation-associated ICH.Main Outcomes and MeasuresDTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined.ResultsOf 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non–vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity.Conclusions and RelevanceIn US hospitals participating in Get With The Guidelines–Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.

Publisher

American Medical Association (AMA)

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