Heparin Bridging During Anticoagulation Is Unsafe After Intracranial Hemorrhage

Withholding anticoagulation for 7 days and longer after intracranial hemorrhage may be safe in patients with mechanical heart valves; however, intravenous (IV) heparin bridging during resumed anticoagulation may increase the risk for bleeding, according to study results published in Neurology.

Researchers conducted a retrospective cohort observational study to explore the associations between reversal therapy and ischemic stroke, duration off anticoagulation and risk for ischemic strokes or systemic embolism, and timing of resumed anticoagulation and risk for rebleeding and intracranial hemorrhage expansion. Adults with mechanical heart valves who were admitted to Mayo Clinic hospitals in New York, Arizona, and Florida for acute intracranial hemorrhage between January 2000 and July 2022 were eligible for inclusion. The primary outcomes were thromboembolic events (ie, cerebral, retinal, or systemic) while off anticoagulation, as well as intracranial hemorrhage expansion (defined as an increase by 1/3 in intracerebral hematoma volume, increase by 1/3 in convexity subdural hemorrhage diameter, or visually unequivocal expansion of other intracranial hemorrhage locations to the naked eye), following the resumption of anticoagulation. The chi-squared, Fisher exact, and Wilcoxon rank-sum tests were used in statistical analyses.

A total of 171 patients (median age, 72; men, 68.4%; traumatic intracranial hemorrhage, 38.9%) were included in the study. Subdural hematoma was the most common (44%) intracranial hemorrhage type and most (66%) patients had mechanical aortic valves. The median duration of hospital stay was 7 days and 25 (14.6%) patients died during the initial hospital stay.

Reversal therapy for anticoagulation was received by the majority of patients (79.5%) and was not associated with an increased risk for thromboembolic complications (P =.10). There was also no difference in the risk for ischemic stroke among patients who were reversed with prothrombin complex concentrate (13.79%) vs fresh-frozen plasma (4.55%; P =.11).

In 82.5% of patients, anticoagulation was resumed. Among the entire cohort, the median number of days off anticoagulation was 10. While off anticoagulation, 11 (6.4%) patients had ischemic stroke or transient ischemic attack. Time off anticoagulation was not related to ischemic stroke or transient ischemic attack occurrence (P =.18) and most patients experienced a stroke after being off anticoagulation for more than 7 days. Only 2 patients had a stroke within 7 days of intracranial hemorrhage, both of whom had additional risk factors for thromboembolism (ie, active cancer, intracranial dissection).

After the resumption of anticoagulation, intracranial hemorrhage expansion occurred in 17 (9.9%) patients. Median time to intracranial expansion following the resumption of anticoagulation was 8 days. Time off anticoagulation was not linked to risk for intracranial hemorrhage expansion (P =.41).

Heparin bridging therapy was initiated in 49 (28.7%) patients. Heparin bridging vs warfarin without a heparin bridge was associated with a significantly higher risk for intracranial hemorrhage expansion (P =.004).

Study limitations include the use of a convenience sample based on data availability, possible confounding, incomplete data, and varying lengths of follow-up.

“Most importantly, we learned that withholding anticoagulation for the first 7 days is safe and that we should avoid bridging with IV heparin when anticoagulation is resumed,” the study authors concluded.