Contemporary Reversal of Oral Anticoagulation in Intracerebral Hemorrhage

I ntracerebral hemorrhage (ICH) accounts for 15% of all strokes and is associated with a high mortality rate and poor functional outcomes. The mortality rate of patients with ICH remains high at 34% in the United States, despite declining incidence in the past 2 decades. Oral anticoagulation is a common cause of ICH and will increase as the prevalence of atrial fibrillation is estimated to increase from 5.6 to 15.9 million by 2050 in an aging US population. 2][3] One study identified that failure to reverse international normalized ratio (INR) within 2 hours was an independent predictor of mortality and morbidity. hese data illustrate the importance of rapid and effective coagulopathy reversal. This article will review the current anticoagulation options for vitamin K antagonists (VKAs) or novel oral anticoagulants (NOACs) and the safety and efficacy of class-specific reversal of coagulopathy in patients with ICH. Andexanet alfa-the second NOAC-specific reversal agent after idarucizumab-was approved by the Food and Drug Administration early this year. We seek to evaluate the efficacy, safety, and cost of these new agents in comparison with older nonspecific reversal options.