1. Prosthetic Valve; Anticoagulation After ICH Dr.Tahsin.N

2. Complications A meta-analysis in 1994 - not anticoagulated  Prosthetic valve thrombosis - 1.8% per patient-year (95% CI 0.9–3.0%).  Mechanical valve embolism resulting in death, stroke or peripheral ischaemia requiring surgery 4% per patient-year (95% CI 2.9–5.2%). This is reduced to 2.2% by antiplatelet drugs and 1.0% per patient-year with warfarin.  Risk of ICH increased by 7–10 fold, to an absolute risk of 0.3–1% per year. The mortality associated with oral anticoagulant related ICH is about 60%  The risk of ICH recurrence - 2% to 4% per patient-year.

3. Lobar hemorrhage or cerebral amyloid angiopathy - higher risk of anticoagulant related ICH recurrence than thromboembolic events – No anticoagulants. Deep hemispheric ICH/ hypertension that can be well controlled and high risk of thromboembolism – Anticoagulation

4. Risk factors - Recurrent bleed Amyloid angiopathy – Lobar haemorrrhage (4% Vs 2%) The presence and number of microbleeds on T2-wted gradient-echo MRI Apolipoprotein E genotype58 High Blood pressure High INR

5. Timing The European Stroke Initiative :patients with a strong indication for anticoagulation should be restarted on warfarin after 10 to 14 days, depending on the risk of thromboembolism and ICH recurrence. The American Heart Association : patients with a very high risk of thromboembolism for whom restarting warfarin is considered, warfarin may be restarted 7 to 10 days after ICH onset. The American College of Chest Physicians : start prophylactic dose heparin the day after an ICH - no clear guidance on restarting warfarin.

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