Key points

A question
In patients with acute ischemic hemorrhage from large vessel occlusion selected for endovascular thrombectomy (EVT), does recent exposure to vitamin K antagonists (VKAs) increase the risk of symptomatic intracranial hemorrhage?

results
In this retrospective registry-based study of 32,715 patients with acute ischemic syndrome treated with EVT, symptomatic intracranial bleeding occurred in 6.8% of VKA-experienced patients and 6.4% of anticoagulant-naïve patients. for oral use. , a difference that was not statistically significant after multivariate adjustment. However, a subgroup of patients with recent VKA use and an international standardized ratio greater than 1.7 had a significantly increased risk of symptomatic intracranial hemorrhage (8.3%) compared with those not taking oral anticoagulants.

Meaning
Among patients with acute ischemic bleeding selected to undergo EVT, recent VKA use was not significantly associated with an increased risk of symptomatic intracranial hemorrhage overall, although the risk was significantly increased among the subgroup of patients with recent VKA use and an elevated global normalized ratio at presentation .

Significance
The use of oral vitamin K antagonists (VKAs) may increase the risk of complications in patients undergoing intrauterine thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion.

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

Design, setting and participants
A 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 United States, 32,715 patients with acute ischemic syndrome were selected to undergo EVT within 6 hours. which are known to be well received.

Contagion
VKA use within 7 days before arrival in hospital.

Main results and measures
The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints were life-threatening bleeding, other serious complication, any complication of reperfusion therapy, in-hospital mortality, and in-hospital mortality or hospital discharge.

results
Of 32,715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used VKA (median international normalized ratio) [INR]1.5 [IQR, 1.2-1.9]) and 29 628 had not used VKA before hospital presentation. Overall, previous VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking VKA compared to 1904/29 628 patients [6.4%] not taking 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 VKA with an INR greater than 1.7, the sICH risk was significantly greater than in those not taking 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%]), but those with an INR of 1.7 or less (n = 1585) had no significant difference in 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 the 5 prespecified secondary endpoints, none showed significant differences between VKA-exposed and VKA-unexposed groups.

Conclusions and Significance
Among patients with acute ischemic stroke selected for EVT, VKA use in the previous 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with an INR above 1.7 was associated with a significantly increased risk of sICH compared with no anticoagulant use.

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