Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke
Authors: Mac Grory Brian , Holmes DaJuanicia N. , Matsouaka Roland A. , Shah Shreyansh , Chang Cherylee W. J. , Rison Richard , Jindal Jenelle , Holmstedt Christine , Logan William R. , Corral Candy , Mackey Jason S. , Gee Joey R. , Bonovich David , Walker James , Gropen Toby , Benesch Curtis , Dissin Jonathan , Pandey Hemant , Wang David , Unverdorben Martin , Hernandez Adrian F. , Reeves Mathew , Smith Eric E. , Schwamm Lee H. , Bhatt Deepak L. , Saver Jeffrey L. , Fonarow Gregg C. , Peterson Eric D. , Xian Ying 
Published: June 2023

Importance

Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications.

Objective

To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice.

Design, Setting, and Participants

Retrospective, observational cohort study based on the American Heart Association’s Get With the Guidelines–Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included.

Exposure

VKA use within the 7 days prior to hospital arrival.

Main Outcome and Measures

The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice.

Results

Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, −0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, −0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups.

Conclusions and Relevance

Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.