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.

Transcript

Speaker 1 0:02

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

The Million Dollar Question

Speaker 1 0:12

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 0:23

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

Retrospective Study Findings

Speaker 1 0:33

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 0:50

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

Key Patient Demographics

Speaker 1 1:00

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

Seven Days as a Starting Point

Speaker 1 1:40

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

Discussion on Restarting Warfarin

Speaker 1 2:00

. 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 .