guideline for antiplatelet, heparin after ICH

[neuronwangyu]

Hey, I have not found a guideline or study for giving asa, plavix, dual-therapy, DVT prophylaxis, heparin drip for NSTEMI after a hemorrhagic stroke.

Please educate

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[HarveyCushing]

Same with anti-coagulation for a pt in a-fib who just had an ischemic stroke. Seems like depending on the neurologist and cardiologist you ask you will get different answers. Depends what their mentors told them in training.

Depends on the size of the stroke and how comfortable they are with any complications that might arise. I usually saw anti-platelet therapy restarted somewhere around 6-8 weeks after when I was on neurology.

"Antiplatelet agent use was not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage (hazard ratio

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0.8, 95% CI 0.3 to 2.3, p = 0.73) or of deep hemorrhage (HR 1.2, 95% CI 0.1 to 14.3, p = 0.88)."
http://m.neurology.org/content/66/2/206.abstract

And another here: www.nature.com/nrcardio/journal/v3/n6/full/ncpcardio0579.html

 

[neuronwangyu]

Thanks. I read those two papers.
Just feel frustrated because some critical decision making we learned during the residency training are just based on preference and fear.

Same with anti-coagulation for a pt in a-fib who just had an ischemic stroke. Seems like depending on the neurologist and cardiologist you ask you will get different answers. Depends what their mentors told them in training.

Depends on the size of the stroke and how comfortable they are with any complications that might arise. I usually saw anti-platelet therapy restarted somewhere around 6-8 weeks after when I was on neurology.

"Antiplatelet agent use was not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage (hazard ratio

---

0.8, 95% CI 0.3 to 2.3, p = 0.73) or of deep hemorrhage (HR 1.2, 95% CI 0.1 to 14.3, p = 0.88)."
http://m.neurology.org/content/66/2/206.abstract

And another here: www.nature.com/nrcardio/journal/v3/n6/full/ncpcardio0579.html

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[Hank Rearden]

Yes, I find it amazing that the 2010 AHA guidelines on ICH don't even broach these subjects. That probably tells you something about how little data there is. I can tell you what I learned to do in my training (of course every case is different so these are just generalities). Start DVT proph 24hrs post. No heparin drip for simultaneous ICH and NSTEMI because risk outweighs benefit. Restart antiplatelet agents 1-2 wks post-ICH. For a very large ICH I wait 2 weeks. If it's a smaller ICH I may only wait 3-7 days before restarting antiplatelet agents. Of course if the patient has cerebral amyloid angiopathy you never put them back on antiplatelet agents. The poster above who doesn't restart antiplatelet agents for 6-8 wks probably reimages with MRI in 6-8 wks to make sure there's no underlying hemorrhagic tumor or vascular anomaly that appears once the blood products have had a chance to resorb. In practice, we almost never find these on follow up MRI, so I empirically start antiplatelet agents sooner.

 

[HarveyCushing]

The poster above who doesn't restart antiplatelet agents for 6-8 wks probably reimages with MRI in 6-8 wks to make sure there's no underlying hemorrhagic tumor or vascular anomaly that appears once the blood products have had a chance to resorb. In practice, we almost never find these on follow up MRI, so I empirically start antiplatelet agents sooner.

Btw, I am just a 4th year medical student. That post by me was based upon my experience with the patients I had seen in outpatient clinic. Not my own patients. He tends to be a little more conservative in general. YMMV.

 

[burs0028]

I'm a vascular fellow at a very busy stroke center that is quite experienced with ICH management. As noted above, data is sparse, but here's what we do:

NSTEMI: heparin drip will kill an acute ICH pt and, as we all know, Brain trumps Heart (any cardiologist who tells you otherwise needs to spend some time in the Neuro-ICU) so no go unless ICH is tiny, and pt is > 1 week out from onset of bleed. Luckily this doesn't come up to terribly often in our patient population. The stress of ICH may create an adrenalin surge and result in a troponin leak AKA supply demand ischemia, but a true NSTEMI in the setting of ICH that calls for anticoagulation is uncommon in my experience

DVT prophylaxis: usually 24-48h post ICH onset. If laying in a hospital bed with complete hemiparesis and inability to express discomfort from a cramping limb isn't a perfect setup for a DVT, then I challenge you to tell me of a better one. ICH pts in general are at extremely high risk of DVT & PE so you really shouldn't neglect the opportunity to prevent them in the absence of any data supporting the "fear" that is so prevalent.

Restarting antiplatelet: a lot of pts with HTN ICH are at significant risk of ischemic strokes too. We restart antiplatelets in days (small hemorrhage) to a week at most (huge bleed). While I think I am rare in my acknowledgement that antiplatelets aren't the 100% effective stroke-preventers we sell them as ("aspirin failure"?!), any additional time off therapy does needlessly increase your patient's risk.

Dual antiplatelet: no real role in ischemic stroke risk reduction*; will only use if there is a strong vascular or cardiac indication (ie. fresh stent in place).
*Given SAMMPRIS methodology, many stroke neurologists now advocating dual antiplatelet use for the first 3 months after identification of an intracranial stenosis followed by single antiplatelet use indefinitely.