Impatto ospedaliero e management pratico delle emorragie cerebrali intraparenchimali spontanee associate a terapia anticoagulante orale nel corso degli anni

  • Luca Masotti
  • Fabio Antonelli
  • Paolo Pennati
  • Marcello Fiorini
  • Luciano Villani
  • Alessandro Pampana
Articolo Originale
  • 35 Downloads

Parole chiave

Emorragia intracerebrale Terapia anticoagulante orale Antagonisti della vitamina K Warfarin Rapporto normalizzato internazionale Concentrato di complesso protrombinico 

Hospital burden and practical management of oral anticoagulant therapy related spontaneous intracerebral hemorrhages over the years

Summary

Background

Spontaneous intracerebral hemorrhage (sICH) represents the most feared subtype of stroke. Despite the intracranial bleeding risk associated to oral anticoagulant (OAT) with vitamin K antagonists (VKA) has remained constant, the wider use of VKA over the last 20 years has proven the increasing of OAT related ICH (OAT-sICH).

Aim of the study

To evaluate whether the percentage of OAT-sICH is increased in our hospital and which has been the practical management of OAT urgent reverse and whether this management has changed over the years.

Methods

We retrospectively analyzed data records of patients consecutively admitted in the Internal Medicine ward of our hospital for ICH since 2006. Of these patients we retrieved clinical, radiological and laboratory findings aimed to investigate the severity of sICH, the antithrombotic drugs used before admission, the INR values in OAT-sICH patients at hospital arrival and after OAT reverse and the mortality burden.

Results

In the analyzed period 122 patients, 56 males, with mean age 79.8±9.6 years, were admitted. 25 patients (20.4%) were on OAT, whereas 44 (36%) were treated by antiplatelets agents. The percentage of OATsICH increased from 9% in 2006 to 31.5% in the first ten months of 2011. 39 patients (31.96%) died. Mortality was 56% in OAT-sICH patients, 40.9% in antiplatelets related sICH, while mortality was 12.8% in patients not treated with antithrombotic drugs. Mean values of INR at hospital arrival were 3.55±2.39. One patient (4%) presented INR value <2.0, 48% of patients was in therapeutic range (2.0–3.0), 28% had INR values between 3.0 and 4.0, 8% 4.0–5.0, 12% INR values >5.0 (8%–9.0). OAT reverse was performed by using prothrombin complex concentrate (CCP) in 80% of patients, whereas 12% was treated with fresh frozen plasm. 96% of patients received intravenous vitamin K1. At the end of first dose of CCP mean values of INR were 1.61±0.76. Median number of INR assays until demonstration of OAT reversal was 3.

Conclusion

OAT-sICH is an increasing emergency due to wider use of VKA. Laboratory physicians are called to give quick results of INR as the urgent OAT reverse is imperative. Therefore close collaboration between emergency and laboratory physicians is fundamental.

Key words

Intracerebral haemorrhage Oral anticoagulant therapy Vitamin K antagonists Warfarin International normalized ratio Prothrombin complex concentrate 

Riassunto

Premesse

L’emorragia cerebrale intraparenchimale spontanea (sICH) rappresenta la forma più temuta di ictus cerebrale. Nonostante il rischio di sanguinamento intracerebrale associato alla terapia anticoagulante orale (TAO) con farmaci vitamina K antagonisti (VKA) sia rimasto costante, il più ampio uso dei VKA negli ultimi 20 anni ha comportato un incremento delle sICH TAO associate (sICH-TAO).

Scopo dello studio

Valutare se la percentuale di sICHTAO è aumentata nel nostro ospedale nel corso degli anni e quale è stato e se è cambiato il management pratico del reverse urgente della TAO nel corso degli anni.

Metodi

Abbiamo analizzato retrospettivamente i dati clinici, strumentali e di laboratorio dei pazienti consecutivamente ricoverati nel reparto di Medicina Interna del nostro Ospedale dal 2006 con lo scopo di valutare la severità clinica della sICH, la terapia antitrombotica assunta prima dell’arrivo in Ospedale, i valori di INR all’arrivo in Ospedale nei pazienti con sICH-TAO e dopo il trattamento di reverse urgente e l’impatto sulla mortalità totale delle sICH-TAO.

Risultati

Nel periodo analizzato 122 pazienti, 56 maschi, di età media±DS 79,8±9,6 anni, sono stati ricoverati per sICH. 25 pazienti (20,4%) assumevano TAO e 44 (36%) antiaggreganti piastrinici prima dell’evento. La percentuale di sICH-TAO è aumentata dal 9% del 2006 al 31,5% dei primi 10 mesi del 2011. 39 pazienti (31,96%) sono deceduti. La mortalità è risultata del 56% nei pazienti con sICH-TAO, del 40,9% nei pazienti in terapia antiaggregante e del 12,8% nei pazienti che non assumevano terapia antitrombotica. I valori medi di INR all’arrivo in Ospedale sono risultati 3,55±2,39. Un paziente (4%) è risultato avere valori di INR <2,0, il 48% dei pazienti erano in range terapeutico (2,0–3,0), il 28% aveva valori di INR compresi tra 3,0 e 4,0, il 8% 4,0–5,0, il 12% valori di INR >5,0 (8% ≥9,0). Il reverse urgente della TAO è stato effettuato nel 80% dei casi con concentrato di complesso protrombinico (CCP), nel 12% dei casi è stato somministrato plasma fresco congelato e nel 16% dei casi fattore VII ricombinante attivato. Il 96% dei pazienti ha ricevuto l’infusione di vitamina K1. Alla fine della prima infusione di CCP i valori medi di INR sono risultati 1,61±0,76. La mediana di dosaggi dell’INR fino alla dimostrazione della neutralizzazione della TAO è stata 3.

Conclusioni

Le sICH-TAO sono un’emergenza medica in incremento e ciò è dovuto alla più ampia diffusione dei farmaci VKA. I Medici di Laboratorio sono chiamati a dare risposte rapide dei valori di INR dal momento che il reverse urgente della TAO è imperativa in questo contesto. La stretta collaborazione tra Medici dell’emergenza e di Laboratorio è fondamentale.

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Copyright information

© Springer-Verlag Italia 2012

Authors and Affiliations

  • Luca Masotti
    • 1
    • 5
  • Fabio Antonelli
    • 2
  • Paolo Pennati
    • 3
  • Marcello Fiorini
    • 4
  • Luciano Villani
    • 2
  • Alessandro Pampana
    • 1
  1. 1.UO Medicina InternaOspedale di Cecina, ASL 6 LivornoCecinaItaly
  2. 2.UO Chimica ClinicaOspedale di Cecina, ASL 6 LivornoCecinaItaly
  3. 3.UO Pronto SoccorsoOspedale di Cecina, ASL 6 LivornoCecinaItaly
  4. 4.UO Laboratorio Analisi Chimico ClinicheOspedale di Livorno, ASL 6 LivornoCecinaItaly
  5. 5.UO Medicina InternaOspedale di CecinaCecina (Li)Italy

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