A 60 year-old woman with HTN and active tobacco use initially presented to the ED with an acute onset of dysarthria and right arm weakness. She was found to have a left putaminal IPH (ICH score 0). You admit her to the NCCU for monitoring for potential hematoma expansion that would necessitate surgical intervention. A 6-hour interval scan demonstrates stability of the hematoma.
On ICU admission day 2, the patient becomes tachycardic to the 140s. You obtain an ECG, though her HR improved in the time it took to acquire this test. Her neurologic exam has remained stable.
You recognize this as a-fib given the lack of P waves and overall irregularly irregular rhythm. You cycle her BP cuff; her BP is 110/78. Looking through prior ECGs, you can tell that she's been documented as having a-fib at least once in the past, though she was in normal sinus rhythm upon presentation here this time.
Her IPH has already been shown to be stable radiographically, and she's been stable clinically. Currently, there's no impending surgical procedure. She can thus be started on DVT chemoprophylaxis at 24 hours from her stability scan, as usual.
So now we get to the crux of the matter for this case. We've now identified the patient as having a-fib. With the given history, she has paroxysmal a-fib, which we know [usually] necessitates therapeutic anticoagulation. She came in with an IPH, though, so we can't possibly start therapeutic anticoagulation, right?
The answer to this is not always black and white. We need to figure out, the best we can, her risk profile of not therapeutically anticoagulating her, and compare it to the more obvious risk profile of proceeding with anticoagulating her. Let's start with the latter. Of course, therapeutic anticoagulation increases the risk of hematoma expansion. This is worse more acutely, but improves over time.
What about the risk of not therapeutically anticoagulating her? So she has paroxysmal a-fib, and she doesn't seem to have had any other cardioembolic events. (If that last part wasn't true, then her risk profile here would increase.) Her CHA2DS2-VASc score is 2 (sex, HTN), putting her annual stroke risk at 2.2% per year. She notably doesn't have a mechanical valve, which would've also raised this risk profile substantially.
In a 2022 systematic review, Puy et al. identified several trials-- few of which were randomized-- that reported timing of resumption of oral anticoagulants and the incidence of thrombotic and hemorrhagic events. There was a great degree of heterogeneity (i.e. some mostly included patients with SDH rather than IPH). The timing of restarting anticoagulation varied. Overall, we still don't have the great evidence for determining the optimal timing of anticoagulation for everyone. So we have to do our best at trying to quantify or qualify the inherent risks. In one study, the cumulative incidence of recurrent ICH in patients without anticoagulation was 4.4%, versus the cumulative incidence of thromboembolic events of 13.8% for that same group.
Putting this all together, while this patient does have an indication for therapeutic anticoagulation due to the risk of cardioembolism, she is relatively low-risk. We can hold off on therapeutic anticoagulation for the next few weeks as we normally would, assuming no new information arises before then (e.g. another embolic event). It's essential that we talk with her and her family about this risk/benefit profile analysis, so that they'll understand that there's risk with either approach (starting it now or waiting). Specifically, while we've identified that we should wait before starting a DOAc, she could very well have an embolic event like an ischemic stroke during this waiting period.
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