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Brilliant Board Review & CME
🎙️ Brilliant Medicine: Your Internal Medicine Edge
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Brilliant Board Review & CME
Episode 28: Warfarin & Brain Bleeds: Restarting After Hemorrhage in Mechanical Valves
🧪 Study:
Retrospective look at patients with intracranial hemorrhage (ICH) on warfarin for mechanical valves.
Followed for stroke, rebleed, mortality.
📈 Findings:
Only 2 strokes in first 7 days after stopping warfarin.
Most resumed warfarin around day 7 with low rebleed risk.
⚠️ Exclusions:
Massive bleeds, unstable patients, large hematomas may require longer delay.
🧩 Clinical Takeaway:
Restarting warfarin at 7 days appears safe in stable patients.
Still a team-based call — include cardiology, neurology, neurosurgery.
now. This is a question of when to resume anticoagulants after brain hemorrhage with mechanical valves, not great research. So when do you restart oral anticoagulants? And is the million dollar question? Usually it's a team approach and sometimes the teams can't get it together and there's some fighting going on between cardiology and the neurosurge. When to now?
Speaker 1:This is a retrospective study and you have to applaud the authors. They did a lot of work on this and this gives us a start. A patient's mean age was 75 years old and they had an intracranial hemorrhage while on oral anticoagulation treatment for mechanicals. What oral anticoagulation is it going to be? Is it going to be a DOAC Negative? No, it's warfarin. Remember, you cannot use warfarin. You can only use warfarin for your mechanical valves, you can't use DOACs.
Speaker 1:This was over a 22-year period. It's assessed the rate of stroke while off the endo-coagulants, the rate of hematoma expansion after endo-coagulant resumption and short-term mortality. Medium follow-up duration was 48 days. In addition to having mechanical valves, 68% had atrial fibrillation. This was a great study. 88% had hypertension this is real and 60% the intracranial hemorrhage was non-traumatic and 60% non-traumatic and the INR was 3 on arrival and 79.5% received reversal therapies for the anticoagulation. Now only two patients had a stroke within seven days to stop an anticoagulation. So maybe seven days is our starting point Now. Is this the perfect study? No, these authors did great work. Is it perfect Now? We still need more information on the optimal time to resume oral anticoagulation. But maybe we can even go even lower than the seven days, and there should be a range of variables including patient age, comorbidities and intracranial hemorrhage size. But this is a start to have a discussion of when to restart Anticoagulation, specifically warfarin after brain hemorrhage in a patient with mechanical valves.