Timing and safety of anticoagulation reinitiation after intracranial haemorrhage in patients with mechanical valves: a meta-analysis
Author(s)
Type
Journal Article
Abstract
Background and aims. In patients with mechanical heart valves (MHV), anticoagulation (AC) interruption following intracranial hemorrhage (ICH) poses a clinical dilemma due to competing risks of ischemic complications and haemorrhagic recurrence. To date, the optimal timing for
resuming vitamin K antagonists (VKA) remains unclear. This meta-analysis aims to quantify the risks of ischemic stroke and recurrent ICH associated with VKA resumption in this population and explore the temporal risk dynamics.
Methods. We systematically searched PubMed, Embase, and Cochrane Library from inception to December 2023 for studies reporting ischemic or hemorrhagic outcomes in adults with MHV who experienced ICH and were considered for VKA resumption. Primary outcomes were ischemic stroke before AC resumption and recurrent ICH after AC resumption. Random-effects meta analyses were performed. Meta-regressions assessed whether timing of resumption influenced risk.
Risk trajectories were estimated using a model-based approach.
Results. Nine studies were included, comprising 435 MHV patients with confirmed ICH included
in the pooled analysis. Mean age ranged from 54.1 to 75 years; 31.3% were female. The pooled
incidence of recurrent ICH after AC reinitiation was 11.4% (95% CI: 8.2–15.6; I² = 0%), ischemic
stroke during AC suspension was 6.1% (95% CI: 4.1–8.9; I² = 0%), valve thrombosis occurred in
3.3% (95% CI: 1.9–5.6; I² = 0%), and mortality in 4.9% (95% CI: 2.0–11.5; I² = 37%). Meta regression demonstrated a significant inverse association between time to AC resumption and risk
of recurrent ICH (regression coefficient –0.039; 95% CI: –0.093 to 0.015; p = 0.13), corresponding
to an approximate 50% relative reduction in risk at 11 days post-ICH. No significant time dependent association was observed for ischemic stroke (coefficient –0.013; 95% CI: –0.065 to 0.039; p = 0.61).
Discussion. In patients with MHV who experienced an ICH, this meta-analysis found that resumption of anticoagulation was associated with a recurrent ICH rate of 11.4% and an ischemic stroke rate of 6.1% during anticoagulation suspension. Meta-regression suggested a lower risk of recurrent ICH with later AC resumption, with a potential risk reduction at approximately 11 days post-ICH. No time-dependent increase in ischemic stroke was observed. Limitations include the retrospective design of most studies and heterogeneous AC timing across cohorts.
resuming vitamin K antagonists (VKA) remains unclear. This meta-analysis aims to quantify the risks of ischemic stroke and recurrent ICH associated with VKA resumption in this population and explore the temporal risk dynamics.
Methods. We systematically searched PubMed, Embase, and Cochrane Library from inception to December 2023 for studies reporting ischemic or hemorrhagic outcomes in adults with MHV who experienced ICH and were considered for VKA resumption. Primary outcomes were ischemic stroke before AC resumption and recurrent ICH after AC resumption. Random-effects meta analyses were performed. Meta-regressions assessed whether timing of resumption influenced risk.
Risk trajectories were estimated using a model-based approach.
Results. Nine studies were included, comprising 435 MHV patients with confirmed ICH included
in the pooled analysis. Mean age ranged from 54.1 to 75 years; 31.3% were female. The pooled
incidence of recurrent ICH after AC reinitiation was 11.4% (95% CI: 8.2–15.6; I² = 0%), ischemic
stroke during AC suspension was 6.1% (95% CI: 4.1–8.9; I² = 0%), valve thrombosis occurred in
3.3% (95% CI: 1.9–5.6; I² = 0%), and mortality in 4.9% (95% CI: 2.0–11.5; I² = 37%). Meta regression demonstrated a significant inverse association between time to AC resumption and risk
of recurrent ICH (regression coefficient –0.039; 95% CI: –0.093 to 0.015; p = 0.13), corresponding
to an approximate 50% relative reduction in risk at 11 days post-ICH. No significant time dependent association was observed for ischemic stroke (coefficient –0.013; 95% CI: –0.065 to 0.039; p = 0.61).
Discussion. In patients with MHV who experienced an ICH, this meta-analysis found that resumption of anticoagulation was associated with a recurrent ICH rate of 11.4% and an ischemic stroke rate of 6.1% during anticoagulation suspension. Meta-regression suggested a lower risk of recurrent ICH with later AC resumption, with a potential risk reduction at approximately 11 days post-ICH. No time-dependent increase in ischemic stroke was observed. Limitations include the retrospective design of most studies and heterogeneous AC timing across cohorts.
Date Issued
2025-10-21
Date Acceptance
2025-07-22
Citation
Neurology, 2025, 105 (8)
ISSN
0028-3878
Publisher
Lippincott, Williams & Wilkins
Journal / Book Title
Neurology
Volume
105
Issue
8
Copyright Statement
Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
10.1212/WNL.0000000000214184
Publication Status
Published
Article Number
e214184
Date Publish Online
2025-09-25