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Introduction: Current guidelines allow the administration of intravenous recombinant tissue plasminogen activator (IV r-tPA) to warfarin-treated patients with acute ischemic stroke (AIS) who have an international normalized ratio (INR) of ≤1.7. However, concerns remain about the safety of using IV r-tPA in this situation due to a conceivable risk of symptomatic intracranial hemorrhage (sICH), lack of dedicated randomized controlled trials and the conflicts in the available data. We aimed to determine the risk of sICH in warfarin-treated patients with subtherapeutic INR who received IV r-tPA for AIS in our large volume comprehensive center.
Methods: Patients who had received IV r-tPA for AIS in a 9.6-year period were retrospectively investigated (n = 834). Patients taking warfarin prior to presentation were identified (n = 55). One patient was excluded due to elevated INR beyond the acceptable range for IV r-tPA treatment. Because of the significant difference in the sample size (54 vs 779), warfarin group was matched with 54 non-warfarin patients adjusted for independent risk factors for sICH (age, admission NIHSS, history of diabetes). Good outcome was defined as mRS of 0-2 on discharge and sICH was defined as an ICH causing increase in NIHSS ≥4 or death. Warfarin-treated group was further dichotomized based on INR (1-1.3 vs 1.3-1.7) and safety and outcome measures were compared between resultant groups.
Results: No significant difference was found between warfarin-treated and the non-warfarin groups in terms of chance of good outcome on discharge (27.8% in warfarin group vs 26.4% in non-warfarin group; p-value >0.05), or the rate of occurrence of sICH (3.7% in warfarin group vs 11.1% in non-warfarin group; p-value >0.05). Furthermore, rate of sICH (5.1% in patients with INR <1.3 versus 0.0% in patients with INR 1.3-1.7; p-value >0.05) or chance of good outcome on discharge (28.2% of patients with INR <1.3 versus 26.7% in patients with INR 1.3-1.7; p-value >0.05) were not found to be different after the warfarin-treated group was dichotomized.
Conclusion: Administration of IV r-tPA for AIS in warfarin-treated patients with subtherapeutic INR <1.7 does not increase the risk of sICH.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105678 | DOI Listing |
Artif Organs
November 2024
US Clinical Development, Medical and Regulatory Affairs, Novonordisk, Rochester, Minnesota, USA.
Background: The objective of this study is to determine the incidence of major bleeding events in patients implanted with continuous flow left ventricular assist devices (CF-LVADs) bridged with enoxaparin (LMWH) compared to intravenous unfractionated heparin (IV UFH) for a subtherapeutic INR on warfarin.
Methods: A single-center, retrospective, cohort study was conducted including patients with CF-LVADs implanted between January 1, 2012 and July 1, 2020 who received at least one inpatient dose or outpatient prescription for LMWH or IV UFH at least 60 days after CF-LVAD implantation. The primary endpoint was the incidence of major bleeding.
Artif Organs
November 2024
Department of Pathology, Cedars Sinai Medical Center, Los Angeles, California, USA.
Background: Appropriate anticoagulation is crucial for the success of left ventricular assist device patients. Currently, there is no consensus on the optimal management of their subtherapeutic INR in ambulatory setting. Our goal is to evaluate both the short-term adverse events and long-term outcomes of enoxaparin bridging at a major transplant center, following the implementation of bridging safety criteria.
View Article and Find Full Text PDFCureus
September 2024
Cardiology, St. Mary's General Hospital, Passaic, USA.
Although the On-X aortic valve (AO) is considered less thrombogenic compared to its counterparts, we present a case where recurrent thromboembolic ischemic stroke occurred, first with a sub-therapeutic, then even with an elevated International Normalized Ratio (INR). A 36-year-old male, the background of On-X AO replacement but no other risk factors, developed thromboembolic stroke twice while on Warfarin, first with INR 1.4, second with INR 2.
View Article and Find Full Text PDFNeurologist
November 2024
Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Italy.
J Pharm Pract
September 2024
One Brooklyn Health, Brookdale Hospital Medical Center, Brooklyn, NY, USA.
The purpose of this case report is to describe a case of switching warfarin to apixaban in a patient on anticoagulant prophylaxis for a patent foramen ovale (PFO)-associated stroke. An 86-year-old Afro-Latina female with a past medical history of cerebrovascular accident (CVA) in 2012 secondary to PFO and diagnosed Atrial Fibrillation (AF). Patient was switched from warfarin to apixaban after 3 months of labile international normalized ratio (INR) levels.
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