Key result
Factor Xa inhibitor-related ICH linked to ~32% lower reversal treatment rates vs warfarin or dabigatran.
Why the study?
Direct oral anticoagulants and warfarin increase intracerebral haemorrhage risk, but data on protocol-guided non-specific 3-factor PCC for factor Xa inhibitor reversal are lacking.
Does the availability of specific reversal agents for warfarin/dabigatran compared to non-specific agents for factor Xa inhibitors improve outcomes and treatment times in patients with anticoagulation-related intracerebral haemorrhage?
Cohort (n=310)
Yes
Does the availability of specific reversal agents for warfarin/dabigatran compared to non-specific agents for factor Xa inhibitors improve outcomes and treatment times in patients with anticoagulation-related intracerebral haemorrhage?
Despite patients with factor Xa inhibitor-related ICH being less likely to receive reversal therapy compared to those on warfarin/dabigatran, there was no significant difference in time to treatment or 30-day mortality.
Rising FXa inhibitor ICH proportions with lower reversal rates signal care gaps; leaves open whether specific agents improve outcomes in this observational cohort.
Background Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran) and warfarin treatment are associated with an increased risk of intracerebral haemorrhage (ICH). Specific reversal exists for warfarin (vitamin K/prothrombin complex concentrate (PCC)) and dabigatran (idarucizumab). Data on protocol-guided non-specific 3-factor PCC for factor Xa inhibitor reversal are lacking. Aims Our retrospective cohort study aimed to assess anticoagulation-related ICH secular trends. We also aimed to compare administration of reversal and antihypertensive treatments, where specific reversal agents were (dabigatran and warfarin) and were not (apixaban and rivaroxaban) available. Methods We included patients with anticoagulation-related non-traumatic ICH of <24 hours duration from South Australian Stroke units (January 2017–December 2023). Outcomes analysed included 30-day mortality and discharge modified Rankin Scale. Secondary outcomes included time to administration of reversal agent, intravenous antihypertensives and time to systolic blood pressure (BP) lowering <140 mm Hg. Results Of 310 included patients (median age 83 (76, 87)), 208 (67%) were in the factor Xa inhibitor group and 102 (33%) in the warfarin/dabigatran group. The proportion of factor Xa inhibitor-associated ICH increased from 3.7% in 2017 to 19.8% in 2023 (p<0.0001). The warfarin/dabigatran group was more likely to receive reversal (57% warfarin/dabigatran vs factor Xa inhibitor 39%, p=0.005). Where administered, time from hospital arrival to reversal did not differ between groups (132 min (94, 231) warfarin/dabigatran vs factor Xa inhibitor 126 (60, 225); p=0.3), nor did time to first dose of intravenous antihypertensives, time to BP <140 mm Hg and 30-day mortality. Conclusion Factor Xa inhibitor-related ICH increased proportionally over the study period. These patients were less likely to receive reversal treatment than warfarin/dabigatran-related ICH. There was no difference between time to administration of PCC and time to antihypertensive metrics. The high mortality in our study underscores the need for effective optimised and timely treatments.
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El‐Masri et al. (2026) conducted a cohort in Anticoagulation-related non-traumatic intracerebral haemorrhage (n=310). Factor Xa inhibitors vs. Warfarin or dabigatran was evaluated on Administration of reversal treatment (p=0.005). Patients with factor Xa inhibitor-related ICH were less likely to receive reversal treatment compared to those with warfarin or dabigatran-related ICH (39% vs 57%, p=0.005).
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