DOAC vs Warfarin Related Non-Traumatic ICH

Written by Alex Chen, MD

Spoon-feed
Compared with vitamin K antagonist (VKA)-related non-traumatic intracerebral hemorrhage (ICH), direct oral anticoagulant (DOAC)-related ICH had less disability, smaller bleeds, and the meta-analysis showed lower in-hospital mortality rates.

Why does this matter?
We are seeing more and more patients on DOACs, and the treatments we use to reverse life-threatening bleeding complications are not as clear-cut as for VKA.  A recent study looked at whether this matters clinically (in terms of morbidity and mortality). The current study attempted to look at clinical outcomes and neuroimaging profiles between patients on DOACs vs VKAs.

“I used DOACs before they were cool… they were NOACs back then” – Some hipster probably
The short story is that DOAC bleeds were smaller and resulted in less neurologic disability.  This was a prospective, multicenter, cross-sectional study which looked at 161 patients (47 on DOACs and 114 on VKAs) admitted from 13 tertiary stroke centers over a 12-month period with non-traumatic ICH on a DOAC or VKA. They also performed a systematic review and meta-analysis of eligible observational studies looking at outcomes among patients with VKA or DOAC-related ICH.  Baseline median ICH volume was larger in the VKA vs DOAC group (24.3 vs 12.8 cm3).  On 24h CT, patients on VKA did not have a significant difference in ICH volume or growth; however, it trended towards being lower in the DOAC group. The patients on VKAs were more likely to have cerebral edema (71% vs 53.2%) and midline shift (45.6% vs 26.1%). This could have been due to patients receiving more volume in the form of FFP and other treatments.  In this study, there was no significant difference in in-hospital mortality, though the meta-analysis showed decreased mortality in patients taking DOACs vs. VKAs.  At discharge and 3-month follow up, the modified Rankin scale (a measure of disability) was worse in those taking a VKA, 4 vs 3.

Source
Direct oral anticoagulant- vs vitamin K antagonist-related nontraumatic intracerebral hemorrhage. Neurology. 2017 Sep 12;89(11):1142-1151. doi: 10.1212/WNL.0000000000004362. Epub 2017 Aug 16. Review. PubMed PMID: 28814457.

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