Intracerebral Hemorrhage Outcomes after Reversal of Subtherapeutic Warfarin: Analysis of Data from GWTG-Stroke

Background Current guidelines recommend reversal of warfarin anticoagulation with intracranial hemorrhages. The benefit of reversing subtherapeutic warfarin anticoagulation in acute spontaneous intracerebral hemorrhage (ICH) is uncertain. Methods An observational cohort used Get With The Guidelines® Stroke registry between January 2015 and January 2022 to determine association of reversal with outcomes for subtherapeutic anticoagulation (INR 1.5 to 1.9). Exclusions were thrombolytics, direct oral anticoagulants, transferring out, or leaving against medical advice. Results The primary outcome (mRS 0-3 at discharge) was assessed among 1868 patients (mean age 73 years, 42% female), which occurred in 188/894 (21.0%) with reversal and 225/974 (23.1%) without reversal (adjusted odds ratio (aOR) 0.80 [95% CI 0.63-1.005]). Ordinal analysis showed higher odds of mRS 0-4 vs. 5-6 with reversal {52.7% vs 42.5% (aOR 1.21 [1.001, 1.48])}. Outcomes not requiring mRS were analyzed among 2569 patients. Mortality or discharge to hospice was lower with reversal {30.6% vs 41.5% (aOR 0.75 [95% CI, 0.63, 0.89])}. Fewer were ambulatory at discharge {25.8% vs 35.7% (aOR 0.68 [0.54, 0.85])}, fewer discharged to home {18.4% vs 21.7% (aOR 0.79 [0.65, 0.97])}, more discharged to skilled nursing {21.0% vs 15.7% (aOR 1.33 [1.08, 1.65])}, and more discharged to rehabilitation {24.9% vs 18.9% (aOR 1.20 [0.98, 1.47])}. Hospital length of stay was longer {median 6 vs 4 days (adjusted risk ratio (aRR) 1.25 [95% CI, 1.13, 1.37]). There was no difference in venous thromboembolism {2.9% vs 2.3% (aOR 1.47 [0.88, 2.46])}. Discussion Reversal of subtherapeutic warfarin with acute spontaneous intracerebral hemorrhage and INR 1.5 - 1.9 was not associated with improvement in functional outcome based upon discharge mRS 0-3 vs 4-6. Patients that received a reversal agent had 25% lower odds of dying in the hospital or being discharged to hospice, but had a longer hospital stay and were less likely to be fully ambulatory at discharge.